AO-ASIF - Instruments & Implants

R.Texhammar C.
Colton
AO/ASIF Instruments
and Implants
A Technical Manual
Contributors F. Baumgart J. Buchanan J. A. Disegi

R. Hertel A. Murphy S.M. Perren
Foreword M. E. Muller
Completely Revised and Enlarged

Second Edition
With Approx. 3000 Figures
Springer-Verlag Berlin Heidelberg GmbH

Rigmor Texhammar, RN
Former Director of Nurse Education
AO International
Fatbursgatan 18A
11828 Stockholm, Sweden
Christopher Colton
M. B., B. S., L. R. C. P., F. R. C. S., F. R. C. S. Ed.
Professor in Orthopaedics and Accident Surgery
at Nottingham University
Senior Orthopaedic Trauma Surgeon and
Consultant Paediatric Orthopaedic Surgeon
at Nottingham University Hospital
Nottingham NG7 2UH, Great Britain
The first edition appeared under the title:

F. SequinfR. Texhammar, AOfASIF Instrumentation
© Springer-Verlag Berlin Heidelberg 1981
ISBN 978-3-662-03034-9
Library of Congress Cataloging·in-Publication Data

Texhammar, R. (Rigmor): AO/ASIF instruments and implants : a technical manu-
al/ R. Texhammar , C. Colton; with contributions by F. Baumgart ... [et al.]. ; with a
fOfeword by M. E. Miiller. - Completely rev. and enlarged 2nd ed. p. cm. Rev. ed.
of: AO/ ASIF instrumentation/ F. Sequin, R. Texhammar.1981. Includes bibliograph-
ical references and index.
ISBN 978-3-662-03034-9 ISBN 978-3-662-03032-5 (eBook)
DOI 10.1007/978-3-662-03032-5
1. Internal fixation in fractures. 2. Surgical instruments and apparatus.
1. Colton, Christopher L. II. Sequin, F. (Fridolin) AO/ASIF instrumentation. III.
Title. IV. Title: AO/ASIF instruments and implants. [DNLM: 1. Fracture Fixation,
Internal-instrumentation. WE 185 T355a 1994] RD 103. 15S47 1994 617.1'5-
dc20 DNLMlDLC for Library of Congress 93-21299 CIP
This work is subject to copyright. AII rights are reserved, whether the whole Of part of
the material is concerned, specifically the rights of translation, reprinting, reuse of il-
lustrations, recitation, broadcasting, reproduction on microfilms Of in other ways,
and storage in data banks. Duplication of this publication Of parts thereof is only per-
mitted under the provisions of the German Copyright Law of September 9, 1965, in © Springer-Verlag Berlin Heidelberg 1981, 1994
its current version, and a copyright fee must always be paid. Violations fali under the Originally published by Springer-Verlag
prosecution act of the German Copyright Law. Berlin Heidelberg New York in 1994
Softcover reprint of the hardcover 2nd edition 1994
The use of general descriptive names, registered names, trademarks, etc. in this publi-
cation does not imply, even in the absence of a specific statement, that such names are
exempt from the relevant protective laws and regulations and therefore free for gen-
eral use. Typesetting: Data conversion by Aprinta, Wemding
Product liability: The publishers can give no guarantee for information about drug
dosage and application thereof contained in this book. In every individual case the re-
spective user must check its accuracy by consulting other pharmaceuticalliterature. 24/3130 - 5 4 3 2 1 0- Printed on acid-free paper
Foreword
The original AO/ASIF Instrumentation manual presented a

concise and complete description of the AO instruments.
Thoughtfully developed by Fridolin Sequin and Rigmor Tex-
hammar, the manual discussed in a clear fashion the purpose
and care of the various AO instruments that are handled by the
operating room staff. One important feature of the first edition
was a detailed checklist of the instruments required for the
more common operative procedures for treating fractures.
Fridolin Sequin was well-suited to author the first edition: his
15 years of experience as a technical engineer for the AO gave
him in-depth knowledge of AO instruments, and he drew on the
clinical knowledge of Rigmor Texhammar, a consultant and di-
rector of the AO courses for nurses. Its original feature of com-
bining a column of text with a column of illustrations meant the
manual quickly became accepted as a standard. By 1981, trans-
lations could be found in English, French, Spanish, and Italian.
Not surprisingly, the manual was very popular.
The success of the first edition and the development of new
AO/ ASIF techniques led to plans for a second edition. Unfortu-
nately, Fridolin Sequin's passing meant the original team could
not carry on with the project, but Chris Colton of Nottingham,
England, stepped in where Fridolin Sequin left off. As director
of one of the strongest orthopaedic trauma units in Great
Britain, he was well-suited to take on this difficult task. The
combined forces of Chris Colton and Rigmor Texhammar led to
a new focus of emphasis for the second edition, which evolved
around providing a reference not only for the operating room
staff, but also for the increasing numbers of young surgeons
who, it was noticed, used the first edition to aid their under-
standing of the operative care of fractures.
Operative fracture care is not only a worthwhile and rewarding
experience for new surgeons, but also a difficult and demanding
task. For this reason, a readily available text outlining both AO
instruments and techniques was needed. The aims of this manu-
al, however, are broader than merely providing a description of
AO instruments and techniques. In chapters written in collabo-
ration with S.M. Perren and other clinicians and researchers
with comprehensive knowledge in the field, the principles and
the history of the AO are updated. A further chapter, by J. Dise-
gi and F. Baumgart, describes the materials used for AO/ASIF
v
instruments and implants. Recently developed AO instruments
and their uses are discussed, and new areas are explored. In or-
der to help emphasize the important aspects of a procedure, an
intraoperative checklist of the surgical steps was developed by
Chris Colton. Since the time a trauma surgeon has to prepare
for a given case is occasionally limited, this checklist will be
extremely helpful. Knowledge of the important steps in a
procedure will also enable the surgical scrub nurse to better
understand the surgeon's work.
Chris Colton has contributed a number of new and important
elements to the second edition. A chapter entitled "Clinical and
Special Assessment" has been added to inform the entire oper-
ating team of recent developments. Clear and reliable informa-
tion is given on such topics as imaging techniques (e. g. tomo-
graphy, magnetic resonance imaging, and ultrasound) and
compartment syndromes, to name just a few. The fracture clas-
sification is included for each anatomic area discussed. The indi-
cations for osteosynthesis, preoperative planning, patient posi-
tioning, operative approach, and AO strategies for treatment
are also discussed at length.
One of the most important aspects of the second edition re-
mains the detailed instrument checklist, which was the respon-
sibility of Rigmor Texhammar and was well-outlined in the first
edition. It has, however, undergone major revisions in the sec-
ond edition: Rigmor Texhammar's profound understanding of
the AO techniques and long association with AO has provided
an essential background to enable her to carefully review and
enlarge upon the original instrument checklists. Much of the
credit for the organization and for the writing of this manual
must, therefore, be given to Rigmor Texhammar.
Between the first and second editions, many new instruments,
implants and operation techniques were developed by the AO.
Not surprisingly, the length of this manual has increased from
300 pages in the first edition to more than 500 pages in the sec-
ond edition and includes three times as many illustrations. Even
so, the presentation of text and illustrations is excellent. Con-
gratulations to the authors and the editor! Noteworthy is also
the contribution of Lotti Schwendener, a collaborator for the
M. E. Muller Foundation in Berne, who has dedicated more
than 10 months of effort to producing thousands of excellent
photographs, the basis for the illustrations included.
This book has gone even beyond the high goals initially set by
Rigmor Texhammar and Chris Colton. It will surely once again
be an orthopaedic 'best seller'. Within this manual, the entire
operating team will find the information essential to know be-
fore any osteosynthesis is carried out. It will certainly become
indispensable in clinics where AO instruments and techniques
are used.
Berne, October 1993 Maurice E. Muller
VI
Preface
The first edition of this book, written by Fridolin Sequin and

Rigmor Texhammar, was published in 1981 as a manual for op-
erating room personnel. In contrast to the AO Manual of Inter-
nal Fixation, it focused primarily on the technical and practical
aspects of the instrumentation and implant inventory. In the
years since then, the AO system has evolved with the accumula-
tion of surgical experience. Thus many instruments have been
developed that are not covered by that landmark work, making
its replacement necessary. Sadly, the death of Fridolin Sequin in
1988 meant that a new team had to be constituted, which gave us
the opportunity to review the content and emphasis of this new
publication.
Since this book addresses the same subject and readership as
the first edition, it inevitably builds upon the former's concepts.
Any similarities of content or style must stand as a tribute to the
original work.
Our experience over the years in discussion with operating
room personnel in numerous countries has shown that a deeper
understanding of the scientific and clinical foundations of surgi-
cal procedures leads to greater ease of assimilation and reten-
tion of details. Knowledge is also the key to a much better sense
of cohesion among the operating team.
This manual is about the techniques used in the AO system. It
does not set out to teach fracture care. It is of value only when
the decision has been made, for whatever reason, to perform an
AO skeletal stabilisation. A consideration of operative proce-
dures (Chap. 7) has been deliberately included and dealt with in
some depth. Some indications are mentioned, but only to guide
the operating room personnel in understanding why decisions
were made.
Maybe it would be reasonable to draw a parallel with the in-
struction manual that comes with a new car. It tells you in detail
how to perform all the actions necessary to use the car safely,
carefully and with maximum effect, how to care for it and re-
duce wear and tear, and how to execute various manoeuvres.
However, it does not tell you when to get into the car and drive
nor where to go!
Those who wish to delve deeper into any of the subjects cov-
ered by this book will find some recommendations for addition-
al study at the end of many sections.
VII
There have been many friends and colleagues who have made
this edition possible. We should like to thank especially our fel-
low authors of the various sections, who are listed in the table of
contents. Furthermore, Lotti Schwendener deserves our special
gratitude for the time and enthusiasm she displayed in produc-
ing such superb photographs. Without these, the book would
have little meaning. The skill and professionalism of our talent-
ed artists, Mrs V Rohrbach and Mr K. Oberli, enrich the text
with incomparable illustrations. The difficult task of sorting and
numbering the illustrations was borne with patience by Petra
Jareke.
Our colleagues in the AO Foundation deserve special mention,
not only for the financial support during the "gestation" period,
but also for their ready availability for advice and help in deter-
mining our accuracy. The publications by M. E. Muller et al.,
J. Schatzker and M. Tile, U. Heim and K. H. Pfeiffer, T. Rtiedi,
A.H.C. von Hochstetter and R.Schlumpf, J.Mast, R.Jakob
and R. Ganz, and of course the 3rd edition of the Manual of In-
ternal Fixation have proved invaluable references for us.
The three manufacturers of the AO/ ASIF instruments and im-
plants are thanked for their support in supplying material for
the photographs.
The staff of Springer-Verlag have earned our gratitude for their
close collaboration in expediting the "delivery" of this new pub-
lication. The customary expressions of gratitude to the typists
will be omitted- we typed it all ourselves- thanks to Microsoft,
IBM and Nescafe -!
The patience and forbearance of our spouses- Bo J areke and J o
Colton- meant that we could devote countless hours to the pro-
duction and refinement of the edited text. Their unjust reward
has been long periods of loneliness interspersed with oases of
time with a tired and stressed companion!
Stockholm Rigmor J areke Texhammar

Nottingham Christopher L. Colton
October 1993
VIII
Contents
1 Introduction: Assumption of Knowledge 1

By R. Texhammar and C. Colton
2 History of Osteosynthesis 3
By C. Colton
3 Atlas of Anatomy 5
3.1 Orientation 5
3.2 Glossary .. 6
4 Basic A 0/ASIF Technique: Aims and Principles 9

By S.M. Perren and J. Buchanan ( 4.1, 4.3 and 4.4),
R. Hertel (4.2), and C. Colton ( 4.5)
4.1 Principles and Techniques in Relation to Bone Healing 9

By S.M. Perren and J. Buchanan
4.1.1 Reduction . . . . . . 10
4.1.2 Fixation . . . . . . . 12
4.1.3 Immediate Function 13
4.1.4 The Principle of Soft Tissue Care 14
4.1.5 The Principle of Biological Fixation 14
4.2 Aims of the AO-Technique: Stability and Biology 15

ByR.Hertel
4.2.1 Technique 17
4.3 Biomechanical Aspects of the A 0/ASIF Technique 19

4.4 Glossary . . . . . . . . . . . 23
IX
4.5 Principles of Bone Grafting .. 30
By C. Colton
4.5.1 Immunology of Bone Grafting 30

4.5.2 Bone Banking 31
4.5.3 Glossary 32
4.6 References 32
5 Clinical and Special Assessment 33

By C. Colton
5.1 Classification of Fractures 33
5.2 General Assessment in Fracture Care 35

5.2.1 Clinical Diagnosis of Fractures . . . . 35
5.2.2 Assessment of Soft Tissues . . . . . . 35
5.2.3 General Medical Overview of Patient 37
5.2.4 Priorities in Polytrauma 37
5.3 Imaging Techniques 38

5.3.1 Radiography 38
5.3.2 Tomography 39
5.3.3 CTimaging . 39
5.3.4 Magnetic Resonance Imaging 40
5.3.5 Arthography 40
5.3.6 Ultrasound . . . . . . . . . . . 40
5.4 Treatment Options Closed Fractures 41

5.4.1 Conservative Treatment 41
5.4.2 Surgical Treatment 42
5.5 Treatment Open Fractures 43

5.5.1 Soft Tissue Surgery 43
5.5.2 Skeletal Stabilisation 44
5.5.3 General Measures . . 45
5.6 Compartment Syndromes 45
5.7 Glossary 46
5.8 References 47
X
6 A 0/ASIF Instrumentation 49
By R. Texhammar
With Contributions by J.A. Disegi (6.1.1, 6.1.2),
F. Baumgart (6.1.3), and A. Murphy (6.22)
6.1 Materials Used for AO/ASIF Instruments and

Implants . . . . . . . . . . . . . . . . 49
6.1.1 Metals Used for A 0/ ASIF Implants 49
ByJ.A.Disegi
6.1.2 Materials Used for AO/ ASIF Instruments 52

ByJ.A.Disegi
6.1.3 The "Mixing" of Instruments and Implants 54

By F. Baumgart
6.1.4 References 58
6.2 Classification of AO/ ASIF Instrumentation 59
6.3 Instruments for Fixation with Large Screws and Plates 60

6.3.1 Standard Instruments . . . 60
6.3.2 Supplementary Instruments 68
6.3.3 Obsolete Instruments . . . 70
6.4 A 0/ASIF Screws for Large Bone Fractures 71

6.4.1 Large Standard Screws . 73
6.4.2 Supplementary Implants 76
6.4.3 Obsolete Implants . . . 76
6.4.4 Fixation Techniques with Large Screws 76
6.4.5 AO/ASIF Instruments for Insertion and Removal
of Large Screws . . . . . . . . . 82
6.5 Plates for Large Bone Fractures 83

6.5.1 Standard Plates . . . . . . . . . 84
6.5.2 Supplementary Plates . . . . . 92
6.5.3 Fixation Techniques with Large Plates 94
6.5.4 Plate Length and Engaged Cortices . . 109
6.5.5 Contouring of Plates . . . . . . . . . . 110
6.5.6 AO/ASIF Instruments for Application of Large Plates 112
6.6 The Cannulated Screw System 113

6.6.1 The 7.0 mm Cannulated Screw System 113
6.7 Dynamic Hip Screw and Dynamic Condylar Screw

Instrument and Implant System 135
6.7.1 DHS and DCS Instruments .. 136
XI
6.7.2 DHS/DCS Implants . . . . . . . . . . . . . . . . . . . 140
6.7.3 Technique of Application . . . . . . . . . . . . . . . . 143
6.7.4 AO/ ASIF Instruments for Application and Removal
of DHS and DCS 150
6.7.5 References . . . . . . . . . . . . . . . 151
6.8 Angled Blade Plates and Instruments 152

6.8.1 Angled Blade Plate Instruments 153
6.8.2 Angled Blade Plates . . . . . . . 156
6.8.3 Technique of Application . . . . 160
6.8.4 AO/ ASIF Instruments for Application and Removal
of Angled Blade Plates . . . . . . . . . . . . . . . . 172
6.9 Small Fragment Instruments and Implants 177

6.9.1 Small Fragment Instruments . . . . . . . . 177
6.9.2 Small Fragment Implants . . . . . . . . . . 187
6.9.3 Fixation Techniques with Small Fragment Implants 195
6.9.4 Instruments for Application and Removal
of Small Fragment Implants . . . . . . . . . . . . . . . 214
6.10 Pelvic Instruments and Implants 217

6.10.1 Instruments for Screws and Plates 217
6.10.2 Supplementary Instruments 220
6.10.3 Pelvic Reduction Instruments 220
6.10.4 Pelvic C Clamp 223
6.10.5 Pelvic Implants . . . . . . . . . 225
6.11 Mini Fragment Instruments and Implants 227

6.11.1 Mini Fragment Instruments . . . . . . . . 227
6.11.2 Mini Fragment Implants . . . . . . . . . 239
6.11.3 Fixation Techniques with Mini Fragment Implants 249
of Mini Fragment Implants . . . . . . . . . . . . . 267
6.12 Intramedullary Nailing Instruments and Implants 271
6.12.1 Standard Instruments for Universal Nailing 272

6.12.2 Supplementary Instruments . . . . . . . . 282
6.12.3 Obsolete Instruments . . . . . . . . . . . . 284
6.12.4 Universal Femoral and Tibial Nails and Locking Bolts 284
6.12.5 Technique of Insertion and Locking
of Universal Femoral and Tibial Nails 286
6.12.6 The U nreamed Tibial Nailing System 310
6.13 External Fixator Devices: Instruments and Implants 320

6.13.1 The Large External Fixator- Tubular System 321
6.13.2 The Small External Fixator 338
6.13.3 The Pinless Fixator 343
XII
6.13.4 The Lengthening Apparatus 344
6.13.5 The Unifix ........ 348
6.14 The Distractor 352

6.14.1 The Large Distract or 352
6.14.2 The Small Dis tractor 357
6.15 The Bone Forceps 358
6.16 General Instruments for Bone Surgery 360
6.17 Wiring Instruments and Implants 362

6.17.1 Instruments and Implants . . . . 362
6.17.2 Supplementary Instruments .. . 366
6.17.3 Tension Band Wiring Technique 366
6.17.4 Instruments for Tension Band Wiring 369
6.18 Bone Grafting Instruments . . . . . . 369

6.18.1 Interchangeable Gouges, Chisels, and Impactors 369
6.18.2 Donor Sites for Bone Grafts . . . . . . 371
6.18.3 Application of Cancellous Bone Graft . . . . 372
6.19 Instruments for Removal of Damaged Screws 372

6.19.1 Instruments . . . . . . 372
6.19.2 Obsolete Instruments 375
6.19.3 Application Technique 375
6.20 Aiming Device . . . . 376
6.21 Compressed Air Machines 380

6.21.1 Compressed Air as Power Source 380
6.21.2 Air Hoses and Exhaust Diffusor 382
6.21.3 Air Machines and Accessories 383
6.22 Care and Maintenance of AO/ ASIF Instrumentation 394

By A. Murphy
6.22.1 Definition . 394

6.22.2 Causes of Corrosion . . . . . . . . . . . . . 394
6.22.3 Care in Preparation For and During Surgery 395
6.22.4 Management Following Surgery . . . . . . 397
6.22.5 Complex Instruments . . . . . . . . . . . . 405
6.22.6 Preparation for and Sterilisation of AO/ ASIF
Instruments and Implants . . . 414
6.22.7 Storage of Sterilised Items . . . . . . . . 420
6.22.8 Cleaning and Care of Implants . . . . . 421
6.22.9 Cleaning and Care of Power Equipment 424
6.22.10 Repair Service . . . . . . . . . . . . . . 431
XIII
6022011 Handling of Retrieved Implants 432
6022012 Handling of Damaged Instruments 433
6022013 References . . . . . . . . . . . . . 433
7 Internal or External Fixation of Various Fractures 435

By R. Texhammar
701 Fractures of the Scapula and the Shoulder Joint 435

701.1 Anatomy •• 0 •• 436
701.2 Assessment 0 0 0 0 437
7.103 AO Classification 437
701.4 Indication for Osteosynthesis- Implants of Choice 437
701.5 Preoperative Planning and Preparation 438
701.6 Checklist for Operative Technique 0 0 0 438
701.7 Special Consideration- Escape Routes 439
701.8 Postoperative Care 439
701.9 Implant Removal 439
701.10 Recommended Reading 439
702 Fractures of the Clavicle 440

70201 Anatomy •• 0 •• 440
70202 Assessment 0 0 0 0 440
70203 AO Classification 440
70205 Preoperative Planning and Preparation 441
70206 Checklist for Operative Technique 0 0 0 441
70207 Special Consideration- Escape Routes 442
70208 Postoperative Care 442
7.209 Implant Removal 442
702010 Recommended Reading 442
703 Fractures of the Proximal Humerus 443

70301 Anatomy . . . . . 443
70302 Assessment 0 0 0 0 443
70303 AO Classification 443
70305 Preoperative Planning and Preparation 444
70306 Checklist for Operative Technique 0 0 0 445
70307 Special Consideration- Escape Routes 445
70308 Postoperative Care 446
70309 Implant Removal 446
703010 Recommended Reading 446
7.4 Fractures of the Humeral Shaft 447

7.401 Anatomy 0 • • • • 447
7.4.2 Assessment 0 0 0 0 448
7.403 AO Classification 448
XIV
7.4.4 Indications for Osteosynthesis- Implants of Choice 448
7.4.5 Preoperative Planning and Preparation 448
7.4.6 Checklist for Operative Technique . . . 449
7.4.7 Special Consideration- Escape Routes 450
7.4.8 Postoperative Care . . . 450
7.4.9 Implant Removal . . . . 450
7.4.10 Recommended Reading 450
7.5 Fractures of the Distal Humerus 451

7.5.1 Anatomy . . . . . 451
7.5.2 Assessment . . . . 451
7.5.3 AO Classification 451
7.5.4 Indication for Oesteosynthesis- Implants of Choice 452
7.6 Fractures of the Olecranon 456

7.6.1 Anatomy . . . . . 456
7.6.2 Assessment . . . . . . . . . 456
7.6.3 AO Classification . . . . . 456
7.7 Fractures of the Radial Head 460

7.7.1 Anatomy . . . . . 460
7.7.2 Assessment . . . . . . . . . . 460
7.7.3 AO Classification . . . . . . 460
7.8 Fractures of the Radius and the Ulna 463

7.8.1 Anatomy . . . . . 463
7.8.2 Assessment . . . . 463
XV
7.8.4 Indication for Osteosynthesis- Implants of Choice 464
7.8.5 Preoperative Planning and Preparation 0 • 0 •• 464
7.8.6 Checklist for Operative Technique (Both Bones) 465
7.8.8 Postoperative Care 466
7.8.9 Implant Removal 466
7.9 Fractures of the Distal Radius 467

7.9.1 Anatomy •• 0 •• 467
7.9.2 Assessment . . . . 467
7.10 Fractures in the Hand 471

7.10.1 Anatomy ..... 471
7.10.2 Assessment . . . . 471
7.11 Fractures of the Pelvis 476

7.11.1 Anatomy . . . . . 476
7.11.2 Assessment . . . . 477
7.12 Fractures of the Acetabulum 483

7.12.1 Anatomy 0 • 0 •• 483
7.12.2 Assessment . . . . 483
XVI
7.12.6 Checklist for Operative Technique ... 486
7.13 Fractures of the Proximal Femur 488

7.13.1 Anatomy ..... 488
7.13.2 Assessment .... 489
7.13.10 Recommended Reading · 493
7.14 Fractures of the Femoral Shaft 494

7.14.1 Anatomy • 0 • • • 494
7.14.2 Assessment .... 495
7.15 Fractures of the Distal Femur 500

7.15.1 Anatomy ..... 500
7.15.2 Assessment 0 •• 0 501
7.15.6 Checklist of Operative Technique 503
7.16 Fractures of the Patella 506

7.16.1 Anatomy ..... 506
7.16.2 Assessment .... 506
XVII
7.16.4 Indication for Osteosynthesis -Implants of Choice 507
7.17 Fractures of the Tibial Plateau 510

7.17.1 Anatomy • • • • 0 510
7.17.2 Assessment . . . . 511
7.17.6 Checklist of Operative Technique ... 512
7.18 Fractures of the Tibial Shaft 515

7.18.1 Anatomy 0 • 0 • 0 516
7.18.2 Assessment . . . . 516
7.19 Fractures of the Distal Tibia "Pilon Fractures" 523

7.19.1 Anatomy • • • • • • • • • 0 •• 0 •• 0 • 523
7.19.2 Assessment . . . . . . . . . . . . . . . . 523
7.19.3 AO Classification (Tibia/Fibula Distal) 523
7.20 Malleolar Fractures 527

7.20.1 Anatomy 0 •• 0 • 527
7.20.2 Assessment . . . . 528
XVIII
7.21 Fractures of the Foot 533

7.21.1 Anatomy . . . . . 533
7.21.2 Assessment . . . . 533
7.22 References . . . . . . . 540
8 AO/ASIFTechnique in Late Reconstructive Surgery 541

ByR.Hertel
8.1 Post-traumatic Deformities 541

8.1.1 Malunion . . . . . . . . . . 541
8.1.2 Delayed Union, Nonunion 542
8.1.3 Segmental Bone Defekt . . 543
8.2 Degenerative and Metabolic Diseases 544

8.2.1 Osteoarthritis . . . . 544
8.2.2 Chronic Polyarthritis 544
8.2.3 Avascular Necrosis 545
8.3 Tumours 545

8.3.1 Benign and Malignant Tumours 545
8.3.2 Metastatic Disease . . . 546
8.4 Congenital Deformities 546

8.5 Glossary . . . . . . . . . 547
XIX
9 Surgical Fixation ofthe Immature Skeleton • • • 0 • 0 549
By C. Colton
9.1 Anatomy of Growth 549

9.2 Growth Plate Injuries 550
9.3 Indications for Surgical Fixation 550
9.4 External Fixation 552
9.5 Glossary • 0 • 0 • 552
10 Infections After Surgical Fixation 553

By C. Colton
10.1 Glossary 554
Subject Index 555
XX
List of Addresses
Baumgart, Frank, Prof. Dr.-Ing.

AOTK Secretariat
Clavadelerstrasse, CH -7270 Davos Platz, Switzerland
Buchanan, Joy, B. Sc.

AO Research Institute
Colton, Christopher
M. B., B.S., L. R. C. P., F. R. C. S., F. R. C. S. Ed.
Professor in Orthopaedics and Accident Surgery
at Nottingham University
Senior Orthopaedic Trauma Surgeon and
Consultant Paediatric Orthopaedic Surgeon
at Nottingham University Hospital
Nottingham NG7 2UH, Great Britain
Disegi, John A.
Materials Development Director
SYNTHES (USA)
1690 Russell Road, Paoli, PA 19301, USA
Hertel, Ralph, M.D.

Department of Orthopaedic Surgery
University of Berne
Inselspital, CH-3010 Bern, Switzerland
Murphy, Anne, RN
Director of Nurse Education
AO International
Clavadelerstrasse, CH-7270 Davos Platz, Switzerland
Perren, Stephan M., Prof. Dr. me d., D. Sc. (h. c.)

AO Research Institute
Texhammar, Rigmor, RN
Former Director of Nurse Education
AO International
Fatbursgatan 18 A, S-11828 Stockholm, Sweden
XXI
1 Introduction: Assumption of Knowledge
Basic Knowledge
It has been assumed from the outset that those using this manu-
al will already be well schooled in standard operating room
practice and procedures. Therefore, aseptic technique, general
surgical instrument preparation, their handling and mainte-
nance, as well as preoperative preparation of the patient in gen-
eral are not discussed in this book. However, considering the of-
ten complex injuries that are dealt with in traumatology and
orthopaedics, a strict adherance to all these basic principles
must be kept in mind.
To obtain optimum benefit from the contents of this technical
handbook in AO/ASIF techniques, a firm foundation in basic
anatomy and pathology of trauma is necessary.
Preoperative Planning
Since this book deals exclusively with the AO technique, only

the AO/ASIF instruments and implants shall be discussed. It
would be impossible to include all the additional instrumenta-
tion and equipment required for the different surgical proce-
dures in operative fracture care. The diverse practices in each
institution regarding table set up or the handling and care of any
other instrumentation must be taken into consideration by the
reader.
Careful preoperative planning is a prerequisite of any fracture
fixation. Once the surgeon has planned the procedure, the oper-
ating team should be informed about the intended surgery. Only
then is it possible for the staff to prepare the necessary material,
ensure its correct function and allow for surgery without unnec-
essary delay.
Surgical Procedures
The step-by-step instructions in this book are intended only to =

0
~
-=0=
-
serve as examples of common uses of the AO/ASIF instruments
and implants; they are not detailed procedural instructions. The
care of each injury must be individualised according to the in- .""s
1
•
jury pattern and other factors relating to the patient. The preop-
erative plan will be what defines the surgical tactics in every
case. Also, the surgical facilities available and indeed the skills
of the surgical team are factors influencing the result.
Teamwork
Another prerequisite for successful surgery is a high degree of

professional expertise and discipline from all the members of
the surgical team. A team approach in trauma care ensures that
the patient receives the best possible treatment and that all
needs are met. Each member of the team has specific responsi-
bilities, and each task is important and must be executed with
skill and conscientiousness.
=
=
~
-=...=
-Q
....=
• 2
2 History of Osteosynthesis
By C. Colton
For thousands of years the only option for the management of

fractures was some form of external splintage. The Egyptians
used palm bark and linen bandages 5000 years ago; clay and
also lime mixed with egg white were used by the ancients, but
the material most commonly used over the ages has been wood.
Wood is still widely used for native splintage in many parts of
the world and has been incorporated into more scientific clinical
practice by some, e. g. Amerasinghe of Sri Lanka has published
good results from functional bracing using shaped bamboo
boards for tibial fractures.
The first attempts at internal fixation took place around 1770 in
Toulouse, France, where two surgeons, Lapejode and Sicre, are
recorded to have used brass wire for cerclage of long bone frac-
tures. John Kearny Rogers used silver wire suture to stimulate
healing of non unions in the 1820s.
The first recorded surgical device for fracture stabilisation was
the griffe (or claw), described by Malgaigne in 1843. This con-
sisted of two sets of paired, curved spikes which could be drawn
together by a turnbuckle and used to approximate the distract-
ed fragments of a fractured patella. This was in effect the first
external fixator, although an instrument much more closely re-
sembling modern external fixation concepts was described by
Dr. Clayton Parkhill of Denver in 1897.
The term "osteosynthesis" was coined by Albin Lambotte

(1866-1955), a Belgian surgeon regarded universally as the fa-
ther of modern internal and external fixation. He devised an ex-
ternal fixator and numerous different plates and screws, togeth-
er with the surgical instruments necessary for their implantation
in fracture surgery. He was, furthermore , a brilliant mechanic
and made all his own instruments and implants in his workshop
in the early stages of his career (in addition, he was a skilled vio-
lin maker and completed 182 violins in his lifetime !).
Although many others worked to develop methods of fixation
of fractures in the first 50 years of this century (Lane, Hey-
Groves, Konig, Sherman, H offmann, Smith-Peterson, to name
a few) , history came to dictate that it should be the Belgian
school that became the vanguard of progress.
3
•
Robert Danis, a surgeon in Brussels, published two books on
osteosynthesis in 1932 and 1949. The second of these works
recorded fascinating observations on the use of rigid fixation
devices. Danis' aim in operating on fractures was to stabilise the
fracture so firmly that treatment of it could then take second
place to the much more important goal of securing recovery of
the soft tissue injury, joint mobility and muscle function, i. e. im-
mediate functional rehabilitation. To serve this end, he devised
a compression plate (coapteur) and, after anatomically reducing
the fracture, he compressed the bone ends together to increase
the rigidity of fixation. He observed that many fractures treated
in this manner healed without external callus formation, which
he called soudure autogene (or welding) and which we nowa-
days would call direct bone healing.
A young Swiss surgeon, Maurice E.Miiller, read Danis' second
book and was both fired with enthusiasm for the concepts of im-
mediate functional rehabilitation after rigid internal fixation ,
and intrigued by the observation of direct bone healing. After
visiting Danis in 1950, Dr. Muller returned to Switzerland to put
these ideas into practice and to investigate this "new" healing
phenomenon. He drew around himself a group of interested
Swiss surgeons and in 1958, at an historical weekend meeting in
Chur, they decided to form a study group concerning issues of
internal fixation of bone - the Arbeitsgemeinschaft fiir Os-
teosynthesefragen, or AO.
This group dedicated itself to research (both basic scientific and
biomechanical) into osteosynthesis, the design of appropriate
instrumentation for fracture surgery and the documentation of
its results. Out of its own success emerged the need to teach the
lessons it had learnt. The AO/ASIF Foundation is now a large,
international organisation whose various commissions run
these activities, all of which are co-ordinated by a Board of
Trustees comprising 90 surgeons from all over the world.
There can be no doubt that this wonderful initiative, born of the
foresight and scientific endeavour of those early pioneers, has
steered the evolution of skeletal surgery in the last 3 decades.
-=
e~·
rl:.
• 4
3 Atlas of Anatomy
3.1 Orientation
Because of the importance of understanding a uniform termi-

nology and as an aid to orientation, please refer to the figure for
a demonstration of the different planes for viewing human
anatomy and for a view of the skeleton from the front.
CRAN 1AL/SUPERIOR
Humerus
Carpus
Y/ Metacarpals
~Phalanges
Tibial tuberosity
Medial malleolus
Ankle --+co=.•/ Lateral malleolus
Talus
~ Metatarsals
5 •
3.2 Glossary
Abduction: Movement of a part away from the midline, e. g. abduction at

the shoulder moves the arm away from the trunk and out to the side.
Adduction: Movement of a part towards the midline, e. g. adduction at the
hip joint moves the leg toward the midline and adduction of both legs
would press the knees together or cross the legs.
Anatomical Position: The reference position of the body, as illustrated in
the figure.
Anterior: The front aspect of the body in the anatomical position. If A is in
front of Bin the anatomical position, then A is said to be anterior to B.
Caudad: Literally "tailward". If A is nearer the "tail", or coccyx, than B,
then A is caudad of B.
Caudal: Pertaining to the tail, or tail region, e. g. caudal epidural injection.
Cephalad: Literally "headward". If A is nearer the head than B, then A is
cephalad of B.
Coronal: This is a vertical plane of the body passing from side to side, so
that a coronal bisection of the body would cut it into a front half and a
back half. It is so called because at a coronation, the crown (corona in
Latin) is held with a hand on either side as it is lowered onto the royal
head; the hands are in the "coronal" plane.
Distal: Away from the centre of the body, more peripheral. For example,
the hand is distal to the elbow, the phalanges are distal to the
metacarpals. In certain instances, it means nearer the end than the begin-
ning; for example, in the digestive system the stomach is distal to the
oesophagus, or in the urinary tract the bladder is distal to the ureter.
Dorsal: Pertaining to the back- or dorsum- of the body in the anatomical
position. An exception is the foot; the top ofthe foot, even though it faces
forward in the anatomical position, is called the dorsum.
Extensor: Adjective from the noun "extension". The muscles which cause
extension of a part are extensor muscles; the surface of a part where
those muscles are found is sometimes called the extensor surface.
Flexor: Adjective from the noun "flexion". The muscles which cause flex-
ion of a part are flexor muscles; the surface of a part where those muscles
are found is sometimes called the flexor surface.
Frontal: Pertaining to the front of the body in the anatomical position. That
part of the skull forming the forehead is the frontal bone. The frontal
plane ofthe body is the same as the coronal plane (see above).
Horizontal: Parallel with the horizon.
Inferior: Literally below or lesser than. In the anatomical position, if A is
lower than B, A is inferior to B. The opposite is superior.
Lateral: Literally, of or toward the side. The side of the body in the anatom-
ical position is the lateral aspect or surface. If A is nearer the side than B
(further from the midline), then A is lateral to B. The opposite is medial.
Medial: Literally, of or toward the middle, or median. The inner side of a
part with the body in the anatomical position is the medial aspect or sur-
face. If A is nearer the middle, or centre-line, than B, then A is medial to
B. The opposite is lateral.
Midline: The centre line of the body in the anatomical position.
Opposition: The action of opposing one part to another; if the pulp of the
thumb is placed in contact with the pulp of a finger, the movement, or ac-
tion, of the thumb is that of opposition.
Palmar: Pertaining to the palm of the hand, e. g. the palmar fascia, the pal-
mar aspect of the fingers.
Plantar: Pertaining to the sole of the foot, i.e. the surface of the foot which
is "planted" on the ground. Examples are the plantar fascia, the plantar
surfaces of the toes. Plantar flexion is a movement at the ankle which
moves the foot downward, or in a plantar direction.
e
~.
Posterior: The back of the body in the anatomical position is the posterior
...=
c;
surface. If A is nearer the back of the body in the anatomical position
than B, then A is posterior to B. Equivalent to dorsal, except in the foot,
<= where the dorsum is anterior in the anatomical position!
• 6
Pronation: The movement of rotating the forearm so that the palm of the
hand faces backward from the anatomical position. Pronation is also
sometimes used to describe a movement ofthe foot into inclination away
from the midline, otherwise called eversion; a pronated foot would bear
more weight on its medial than its lateral border
Proximal: Nearer to the centre or midline of the body in the anatomical po-
sition. The opposite of distal. Thus, the elbow is proximal to the wrist. In
certain instances, it means nearer the beginning than the end; for exam-
ple, in the digestive system the stomach is proximal to the ileum, or in the
urinary tract the kidney is proximal to the bladder.
Sagittal: Literally, it means pertaining to an arrow (sagitta is Latin for ar-
row), so-called because an arrow fired into the body would normally
strike from the front and would thus pass in a sagittal direction. Bisection
of the body in the sagittal plane would divide it into left and right halves.
Superior: Literally above or better than. In the anatomical position, if A is
higher than, or above, B, then A is superior to B. The opposite is inferior.
Supination: The movement of rotating the forearm so that the palm of the
hand faces forward in the anatomical position, that is restoring the hand
to the anatomical position. Supination is also sometimes used to describe
a movement of the foot into inclination toward the midline, otherwise
called inversion; a supinated foot would bear more weight on its lateral
than its medial border
Transverse: Meaning across. Transverse bisection of the body in the
anatomical position would divide it into upper and lower halves. Not the
same as horizontal, which means parallel with the horizon. Thus if the
body were lying flat on its back (supine), horizontal would be the same as
the coronal plane (see above), but if the body were standing, in the
anatomical position, horizontal would be in the transverse plane. In oth-
er words, horizontal is always related to the horizon, whereas the
anatomical planes (coronal, frontal, sagittal, transverse) always relate to
the anatomical position.
Valgus: Deviation away from the midline in the anatomical position. Thus
genu valgum is a deformity at the knee where the lower leg is angled
away from the midline (knock knee). By convention any deformity, or
deviation, is described in terms of the movement of the distal part.
Varus: Deviation toward the midline in the anatomical position. Thus genu
varum is a deformity at the knee where the lower leg is angled toward the
midline (bow leg). By convention any deformity, or deviation, is de-
scribed in terms of the movement of the distal part.
Vertical: Upright. Perpendicular to horizontal. Derives from vertex -the
top, as in the vertex of the skull.
7 •
4 Basic AO/ASIF Technique:
Aims and Principles
By S.M. Perren and J. Buchanan (4.1, 4.3 and 4.4),
R. Hertel (4.2), and C. Colton ( 4.5)
4.1 Principles and Techniques in Relation

to Bone Healing
The human skeleton gives the body rigidity, allows for locomo-
tion and protects the organs. The figure shows that intact corti-
cal bone is very strong. A segment of the tibia is able to carry a
small car, and a screw inserted into the cortex of the thigh bone
(femur) will take the load of three persons. Intact healthy bone
resists appreciable amounts of load without failure, for exam-
ple, when a parachute jumper lands. When bone is mechanically
overloaded, for example by work or a traffic or sports accident,
it fractures. Prior to the accident the bone was able to carry load
without giving way. After the accident the fractured bone bends,
buckles, shortens or twists when even a small load is applied.
Strength of bone. Bone is a comparatively strong

material. Its strength by far exceeds the require-
ments of heavy physical activity. a Compressive
strength. A short segment of the tibial diaphysis is
able to carry the weight of a small car. b Holding
strength of a screw within cortical bone. A stan-
dard 4.5 mm cortex screw, anchored in only one
cortex, can withstand 2500 N (the weight of three
persons).
a b
The fracture occurs within a fraction of a thousandth of a sec-

ond. An experimental study by Robert Moor showed that dur-
ing the actual fracturing, the soft tissues in the vicinity of the
fracture undergo considerable damage due to the violence of
the fracture. As a consequence, not only the bone but also the
blood vessels and the periosteum are damaged.
9 •
The nature of the fracture pattern depends on the type of force
which led to the fracture: if torque is applied (e.g. skiing), the
fracture shows a spiral pattern. If, however, a bending force is
applied (e. g. when the bumper of a car hits the leg of a pedestri-
an), then a transverse fracture is produced. Similarly, too large a
tensile force may disrupt the patella or the olecranon or avulse a
a
malleolar fragment. When a person lands hard, for example, af-
ter jumping from a balcony, the bone is compressed and the frac- === -
tured limb will probably be shortened.
300 }IS
Different mechanical conditions and types of

healing at the same fracture ite. Different
condition at a fracture site at dirfercnt times
of observation (tension band wiring of th e ole-
cranon). The preload exerted by the wire is The bone fracture. The sequence of events result-
shown by black triangles (static compression) ; ing in a spiral fracture with additional (butterfly)
the changing load due to function, i.e. pull of fragment analysed using high~speed cinematog-
the triceps muscle and related articular com- raphy. A human cadaver tibia was fractured using
pres ion producing additional compression o f
axial torque. The process, which resulted in a but-
the fracture surface, is shown by open arrows.
terfly fracture, was recorded at 10 000 frames per
second (Moor et al. 1989). a Tissue trauma.
When the applied torque reaches the limit of the
strength of the bone, the bone fractures and a gap
4.1.1 Reduction opens up abruptly. A temporary vacuum is creat-
ed. This is succeeded by implosion, the effect of
which can be compared to that of cavitation in
The first specific action in the treatment of a fracture consists of high-velocity gunshot wounds. Marked tissue
reducing the fragments to reinstate the shape of the bone before trauma in the areas of cavitation results. b Se-
quence of events and timing. The schematic dia-
it fractured. This process is called "reduction". Reduction basi- gram shows the sequence of events in the process
cally reverses the forces that led to the displacement: if the frac- of fracturing. Within 400 s the fracture is fully de-
ture was produced by an external rotation of the foot, then re- veloped. The sequence leading to the dissolution
of the butterfly fragment is also shown.
duction will involve applying a moment to produce internal
~ rotation. This neutralises the displacement brought about by
~ the external rotation. The reduction may be achieved using one
·E of the following procedures.
=--=
= =
e 4.1.1.1 External Reduction
~
~ A fracture dislocation may be reduced by applying a force "by
·2' hand". The problem with this procedure is that it is difficult to
'5 achieve optimal reduction.Very often massive manipulation re-
~ suits in considerable trauma of the soft tissues. Furthermore, if
(.J
·;;; soft tissues such as tendons are caught within the fracture, re-
~= duction may be impossible.
• 10
4.1.1.2 Direct Surgical Reduction
When external reduction is impossible or insufficient, then the

reduction may take place by surgical fixation after exposure of
the fracture fragments. These fragments are manipulated using
special forceps and the fragments are reduced. Such reduction
normally results in perfect restoration of the original shape.
Perfect restoration may be required when treating articular
fractures , although it is not mandatory for optimal function in
the case of shaft fractures.
Precise anatomical reduction is required. Frac-
tures which compromise articulating surfaces of
joints result in post-traumatic arthrosis due to 4.1.1.3 Indirect Surgical Reduction
overload following the loss of even stress distribu-
tion.
Indirect reduction is a process of reduction whereby the frac-
ture fragments are not directly manipulated by the hands of the
surgeon or with forceps . A classic example of indirect reduction
is the insertion of pins, such as those used for external fixation,
into the bone. The free end of these pins is then guided by a spe-
cial device called a distractor or by an implant such as a plate.
The mere application of distraction, i. e. pull along the axis of
the bone, results in an astonishingly good reduction of a multi-
fragmentary fracture. Mast and coworkers (1989) have provid-
ed the first systematic description of "indirect reduction". Since
the fracture displacement usually results from the compressive
forces arising from the pull of the muscles, the application of dis-
traction is frequently appropriate. Very often the fragments of a
comminuted fracture are still connected to the soft tissues. Un-
der these conditions, the application of traction by indirect
means, for example, by the distractor, plates or nails, reduces
the fracture sufficiently to ensure good function later on. Con-
siderable traction can be applied with the distractor without
causing the kind of soft tissue damage which results from the ap-
plication of external force by hand.
4.1.1.4 Surgical Reduction and Bone Healing
A fracture in a wild animal may heal solidly even if it remains

untreated. It can be assumed, however, that an untreated frac-
ture will unite with more difficulty under conditions of
malalignment because the displacing forces to be overcome by
the healing process are greater if the bone is bent than if it were
straight. The speed and quality of bone healing is influenced by
the damage due to manipulation in external reduction and/or by
the exposure necessary in internal reduction. For example, cal-
Fracture healing without treatment. The frac- lus formation in open reduction and i. m. nailing is least at the
tured femur of a dog united solidly without treat- surface where surgical intervention damaged the periosteum.
ment ; however, marked malalignment resulted.
The fracture was not reduced or splinted. (Cour- Indirect reduction as proposed by Mast and coworkers repre-
tesy of G. Sumner-Smith). sents a major breakthrough in the improvement of fracture
treatment.
11 •
4.1.2 Fixation
The fracture displaces the bone fragments and the surgeon re-
duces the fragments, but once the fragments are in place again,
they must be maintained in this position. This can be achieved
by external splinting, traction or internal fixation.
4.1.2.1 Stability and Lack of Tissue Irritation
The movement of fracture fragments in relation to each other is

painful. The stability resulting from fixation suppresses the mo-
tion of these fragments and thus alleviates pain. The stability of
fixation is therefore an important element in preventing irrita-
tion and dystrophy (i.e. swelling, pain and reduced articular
mobility).
4.1.2.2 Stability and Direct Tissue Differentiation
The stability of fracture fixation determines the amount of cal-

lus that is formed. An unstable fracture site will soon be sur-
rounded, bridged and stabilised by a cuff of bone called callus
(scar). In general, one can state that the more movement there
is, the more callus is produced. The appearance of callus indi-
cates a reaction which helps the fracture to unite. Therefore, al-
though the surgeon in general likes to see callus, in some cases
of internal fixation the appearance of callus is a sign of unwant-
ed instability. This explains the paradox that the surgeon may
not like to see callus, but the callus will help heal the fracture.
4.1.2.3 Stability and Painless Function
Once a certain degree of stability of fixation has been attained

the injured limb can be moved without pain. Immobilisation of
~ the joints of a limb results in stiffness of those joints, and this
'a may bother the patient more than the fracture itself. Early func-
:~ tion prevents joints from becoming stiff. Since stable internal
=. fixation allows for early movement of the joints, the major ad-
1 vantage of internal fixation is early and complete recovery of
limb function.
~
=
=" 4.1.2.4 Stability of Fixation and Bone Healing
~
..."'
~
(.I
Stability of fixation is synonymous with prevention of move-
ment at the fracture site. Movement of the fracture fragments
== induces callus formation and, as we will see later, induces bone
• 12
surface resorption of the fracture fragments and enhances indi-
rect bone formation. Thus, stability of fixation has a very impor-
tant influence on the healing pattern of bone. In the rare case of
absolutely stable fixation without any motion at the fracture
site, the fracture may unite without callus formation. This type
of healing was preferred for several decades. Today we know
that this type of healing is of little importance as long as the frac-
ture unites early and without complication.
4.1.3 Immediate Function
It has been mentioned above that the primary goal of fracture

treatment is to achieve early and completely undisturbed limb
function.
4.1.3.1 Avoidance of Dystrophy
Dystrophy, which consists in swelling, pain and stiffness of the

joints, must be avoided whenever possible. It was shown by a
study of the Swiss National Insurance company that the greatest
loss of work capacity following bone fracture is not due to retar-
dation of healing but to dystrophy.
4.1.3.2 Maintenance of Articular Mobility
The best means of avoiding dystrophy is full movement of the

articulations as soon as possible after fracture. Today fracture
treatment also deals with the soft tissues as part of the early
restoration oflimb function.
4.1.3.3 Psychological Health
Early restoration of limb function plays an important role in the

psychological health of the patient. The injured patient who can
function normally soon after the injury and care for himself and
his daily needs, such as taking a shower, will overcome the men-
tal injury of being temporarily handicapped sooner.
4.1.3.4 Immediate Function and Bone Healing
Blood circulation is at the basis of bone healing, which means

that anything which improves or maintains blood circulation to
the bone is a top priority.
13
•
4.1.3.4.1 Bone Structure
As we will see later the uninterrupted blood supply to the bone

is important for preventing bone porosis, i.e. a loss of bone with
the appearance of small pores within the bone.
4.1.3.4.2 Induction of Bone Formation
In the long term, bone reacts to unloading with loss of structure.

In this respect bone can be understood as a structural material
which reinforces itself under increased load and loses structure
under conditions of lack of mechanical stimulation.
4.1.3.4.3 Bone Healing Pattern
Immediate function is more important for maintaining the in-

tegrity of the locomotor system than for the pattern of bone
healing. Indirectly, the bone healing process is enhanced by a
perfectly functioning blood supply resulting from optimal re-
covery of limb function soon after the fracture and its treatment.
4.1.4 The Principle of Soft Tissue Care
In the early days of internal fixation, the surgeon approached

the bone without paying much attention to the soft tissues. It
was assumed that the periosteum had little to do with fracture
healing. In contrast to this outdated attitude, we now know that
every detail is important, the incision, the approach to the bone,
avoidance of stripping the periosteum, the fixation of the im-
plant and its contact to bone. These are all factors which con-
tribute to the recovery of function and to undisturbed bone
healing. Any tissue from which the blood supply is cut off, be it
soft tissue or bone, will be liable to infection.
4.1.5 The Principle of Biological Fixation
Clinical results of a procedure called biological internal fixation

have recently proved very successful. Biological internal fixa-
tion is a term which points to the fact that this procedure tries to
~ preserve the biological reactivity of tissue as much as possible.
=- The less the blood supply to the bone fragments is disturbed, the
]~ better the formation of callus and the better the resistance to in-
~ fection.
-~ The term "biological internal fixation" does not mean that now
==
riJ
for the first time fracture healing is biological. However, it does
• 14
indicate that for the first time special care is given to both the
soft tissues and the bone. Characteristic of biological internal
fixation is that it does not view technical fixation as more impor-
tant than the biological milieu of the healing fracture.
Biological internal fixation means very careful dissection, indi-
rect reduction and a minimum of fixation. For example, special
care is taken not to devascularise the bone fragments far from
the plate. One would expect the lack of "medial support" to re-
sult in implant failure due to fatigue. This danger is offset by the
fact that a bone bridge is formed early on and supports the "me-
dial" cortex, thus unloading the implant.
Bone healing after "biological" internal fixation is seen to fol-
low the well known course of indirect bone healing. With flexi-
ble fixation, one would expect the deformation of the soft tis-
sues to impede fracture healing, but the fact that the fracture is
not simple but multifragmentary and that exact adjustment is
not imperative reduces critical tissue deformation. This all helps
to explain why fracture treatment using biological internal fixa-
tion seems to be exceedingly successful.
4.2 Aims of the A 0 Technique:

Stability and Biology
ByR. Hertel
The aim of fracture treatment is to restore full function and in-

tegrity. The best possible long term function of the injured tis-
sues including their cosmetic appearance should be obtained.
Treatment methods are customised to the given injury. Possible
pitfalls, time off work and global costs have to be considered.
The basic problem which led to the development of skeletal fix-
ation systems has remained unchanged: dissatisfaction with the
functional outcome of some conventionally treated fractures.
Increasing experience has helped us recognise the importance
of soft tissue trauma. Indeed, a given radiologic fracture pattern
may be treated by different fixation methods, depending upon
the nature of the soft tissue injury. It is essential to focus atten-
tion on the global musculo-skeletal injury pattern, which defini-
tively determines the practical approach to any given fracture.
The challenge is to reach the overall aim of restoring full func-
tion and integrity, carefully avoiding any potential serious com-
plications. Since the inception of AO teaching, atraumatic, or
better oligotraumatic, tissue handling has been given high prior-
ity. Poor planning and rough surgery may lead to additional
devascularisation. The resulting necrosis is prone to infection.
Necrosis and/or infection may lead to nonunion and to skeletal
and soft tissue defects which are difficult and time consuming to
15
•
remedy. Avoiding ischaemia and necrosis should therefore be
our principal short term objective.
There are circumstances where iatrogenic damage is inflicted by
a lack of treatment. The missed compartment syndrome is one
example. Ischaemia due to high intracompartmental pressure
(swelling of the contused muscle) may lead to total muscle
necrosis. Inadequate initial debridement, in combination with ~m
additional devascularisation by poor fixation technique, may
lead to irreparable damage. As a general rule, only living tissue,
including bone, has the capacity to heal. We will refer to this as
the biological potential of the tissue. Alongside this, there is the
undoubted need for some degree of stability for a fracture to
heal. How much stability is needed does, curiously enough, not
depend as much on the type of fracture itself as on the type of
fixation. A theoretical explanation can be sought in Perren's cell
strain theory. The essential message is that the smaller the frac- Large strain in small gaps. The elongation of cells
ture gap, the higher the strain on the interposed cells. Thus, or tissue is critical. Above the critical value a dis-
turbed function or even rupture will occur. a A
plate osteosynthesis which leaves very small fracture gaps is vul- small displacement in the gap is tolerated by the
nerable in this regard. In fractures with minimal additional soft cell. b A slightly larger displacement results in
tissue trauma and no major endosteal or periosteal devasculari- rupture of the cell.
sation, a simple cast (provided that alignment and length are
correct) leads to reliable and rapid bone union, leaving no per-
manent functional impairment. In the presence of a poor bio-
logical potential, the fixation needs to be more long standing, al-
though additional devascularisation must be minimised.
The practical aims of internal fixation have been gradually re-
vised in the light of experience and adapted to different fracture
situations. For intra-articular fractures anatomical reduction is
mandatory, but reduction and internal fixation must preserve
their vascularity. For meta- and diaphyseal fractures, although .. ..
~~-~·--~:---~~ -~;;.~- ~~--~~~
correct length and spatial alignment are necessary, anatomical :-=-------.. _;::==------ -----------
reduction of all fragments is not considered mandatory. Reduc-
- ~ • ..., •
tion and internal fixation must preserve the healing potential,
which is easily destroyed by too aggressive surgical exposure of b
the fracture. The degree of stability needed is adapted to the 4'6~m
fracture pattern. Optimal, not maximal, stability is required. Small strain in large gaps. The strain on the indi-
The biological status of the injury site must never be compro- vidual cell can be reduced by widening the frac-
ture gap. The global displacement is shared by
mised to achieve a mechanical goal. multiple tissue elements (e.g. cells). a A small
displacement in the gap is tolerated by the cell.
b A larger displacement is still tolerated .
• 16
4.2.1 Technique
Medullary nailing fulfils many of the criteria for biologically

successful osteosynthesis. When performed as a "closed" proce-
dure, it is minimally invasive and yields sufficient stability. Un-
fortunately, reaming of the medullary cavity greatly impairs
bone circulation. In a sense there is an antagonism between
Reamed intramedullary nailing. Reaming de- biology and mechanics. R ecently a new generation of unreamed
stroys the endosteal vascularity by direct strip- nails has become available, which leave the cortical circulation
ping of the vessels, by microembolisation and by relatively undisturbed. Improved design will hopefully yield op-
heat. This results in ischaemia of the central part
of the cortex (slotted area). timal stability, whilst preserving a maximum of biological poten-
tial.
In plate osteosynthesis, mainly indicated for epi-, metaphyseal
or multilevel fractures, two main considerations remain the key
for biological osteosynthesis: the surgical approach and the
technique of reduction. The surgical approach must be chosen
according to the soft tissue condition. As a general rule, it is wise
to include any traumatic laceration in the surgical approach;
this allows debridement of contused tissue and preserves the in-
Unreamed intramedullary nailing. The introduc- tegrity of the remaining tissues. The bone should be minimally
tion of a nail without reaming leads to minimal exposed. Subperiosteal exposure of bone must be abandoned
circulatory disturbance ofthe cortex.
for epiperiosteal dissection. Not more than half of the bone cir-
cumference should be epiperiosteally exposed. Generous
lengths of incisions will help to avoid inadvertent stripping dur-
ing manipulation.
The technique of reduction is of paramount importance since
periosteal stripping is frequently due to repeated unsuccessful
reduction manoeuvres. The surgeon's frustration leads to a
more aggressive handling with forceful reduction, followed by
an even stronger devascularisation of the bone. Conventional
manual reduction is often cumbersome and time consuming.
The worst aspect is the repeated application of bone clamps for
unsuccessful reduction manoeuvres, which may lead to massive,
Nonevascularising surgical approach. The bone is circumferential stripping of the periosteum and devitalisation
exposed trough generous skin incisions, but the
of the fragments. Indirect reduction techniques will help to
periosteal circulation is respected. Epiperiosteal
exposure leaves a thin layer of tissue over the ex- avoid these errors and are always applicable.
posed part of the bone, thus preserving most of its
circulation. At least half of the bone circumfer-
ence is left untouched. It is important to be ex-
tremely careful with Hohmann retractors to avoid
involuntary soft tissue stripping.
17 •
Indirect reduction technique.
A A long condylar plate is fixed to the proximal
main fragment, regardless of the position of the
distal fragments. B Indirect reduction of the
main fracture plane, utilising the plate to distract
and reduce the fracture, is prepared. The articu-
lated tension device is mounted in the distraction
mode and a critically positioned VerbrUgge clamp
is applied. C Simultaneous distraction and tight-
ening of the clamp leads to approximative reduc-
tion in slight overdistraction. Length, axis and
rotation are controlled. D Compression of the
main fracture plane with the articulated tension
device leads to high primary stability. Finally, the
critical screws are introduced (two on each main
ID fragment). Reduction and stabilisation of the me-
dial fragments is not attempted to avoid addition-
al vascular damage.
A 8 c D
The first step after epiperiosteal exposure is to identify the key

fracture plane. Next, preliminary plate fixation to a major prox-
imal or distal fragment in the expected axial alignment is per-
formed. Approximate reduction and placement of a reduction
clamp to hold the plate is followed by distraction either with the
articulated tension device or a conventional distractor.
The second step of reduction, carefully controlling the major
fracture plane for rotational and axial alignment, is carried out
using a pointed bone clamp applied carefully to strategic points.
Finally, compression is applied with the articulating tension de-
vice to at least 1500 N (green ring) and the crucial screws insert-
ed. The exact site of compression is relatively unimportant. It is
certainly not necessary to fill all the screw holes. Judicious use of
screws helps avoid unnecessary additional necrosis, known to
occur after drilling and insertion of screws (cylindrical se-
questrum due to heat and crush). The minimum number of
screws is at least two on each side of the main fracture. For bet-
ter leverage rather longer plates are advocated.
In some instances, a combination of external and internal fixa-
tion is preferable. This is especially true for comminuted
~ epimetaphyseal fractures of the proximal tibia since the use of
~ bilateral plates can seriously jeopardise bone and skin circula-
·E tion. The combination of a unilateral plate and an external fixa-
~ tor (buttress), which temporarily replaces the contralateral cor-
; tex, is one possible way to satisfy both biology and mechanics. Combination of plate and external fixator. The
e"' In extensive, combined trauma it is occasionally preferable to use of an external fixator, as a substitute for an ad-
< opt for a staged procedure. In the acute phase, debridement is

followed by external fixation to avoid additional trauma associ-
ditional plate, has proven very effective in dimin-
ishing surgical trauma.
ated with the application of an internal stabilising device. After

soft tissue recovery, generally a few weeks, definitive internal
fixation can be safely performed.
Another aspect of "biological osteosynthesis" is the refinement
in implant design and material. Plates, for instance, have
• 18
evolved from a broad contact area with the bone to a limited
contact design. Limited contact plates produce less circulatory
disturbance of the underlying bone than full contact plates.
Nails have evolved to the unreamed design since reaming was
recognised as potentially harmful due to the destruction of the
medullary vascular network, in addition to causing microem-
bolisms and direct thermal lesions. External fixation is being
a improved. A "radial preload" Schanz screw promises reduction
of pin track problems. A newly designed "pinless" fixator is
clamped on the bone surface, thus avoiding the perforation
needed for the insertion of standard Schanz screws.
4.3 Rio mechanical Aspects

DCP (dynamic compression plate) and LC-DCP
(limited contact dynamic compression plate). of the A 0/ASIF Technique
a The conventional plate has a wide contact area
with the bone. In the underlying cortex a zone of By S.M. Perren and J. Buchanan
ischaemia is created. b The LC DCP minimises
the contact area and thus the zone of cortical is-
chaemia. Note the position of the plate over the
periosteum. It is obvious that the process of bone fracture changes the bone's
mechanical conditions. It is suddenly no longer intact but bro-
ken up into two or more pieces, it is no longer capable of carry-
ing load, its fragments are unstable and produce pain. As we
pointed out in Sect. 4.1, there is a close relationship between the
degree of mobility (instability) of the fracture and the amount
of callus produced. The mechanical conditions obviously con-
trol the biological reaction: In the context of our work "biome-
chanical" refers to the biological reaction to mechanical input.
The mechanical input may be motion or force. The weight of a
person loads the bone and thus produces internal stresses. If ex-
cessive load is applied to the bone, the bone breaks. If, on the
other hand, a bone is unloaded, it loses its structure and be-
comes porotic, i.e. small holes appear within the unloaded
bone.
As we will see later, the reaction of bone to loading is less impor-
tant than the reaction of bone to instability. The surface of bone
does not tolerate motion well. Instability (motion at the fracture
site) induces resorption and shortening of the fracture frag-
ment. This is a process which under normal conditions enables
bone to heal in spite of instability. Since the resorption increases
the width of the fracture gap, the repair tissues in the fracture
gap are less deformed and it is less likely that they will be dis-
rupted. In internal fixation, motion between bone fragments
and between an implant and bone induces surface resorption,
which results in loosening of the fracture fixation and may
therefore result in initial microinstability turning into gross in-
stability, which might impede fracture healing. These are exam-
ples of the relation between mechanical input and the biological
reaction of bone. This relation determines to a great extent the
19
•
type of fracture healing resulting from the different mechanical
conditions that may prevail when a variety of internal fixation
techniques are used. We will now discuss these techniques with
special reference to the reaction they induce in fractured and in-
tactbone.
When a surgeon reconstructs a patient's broken leg, he puts the
fractured pieces back into place, holds them together with for-
ceps and inserts a screw that catches in only one fragment of the
fracture while the other fragment is held by the head of the
screw resting against the surface of the bone. This technique is
called the lag screw technique. The important feature of this
technique is that of the two fracture fragments only one is in
contact with the thread of the screw. The other fragment, name-
ly, the one near the head of the screw, can glide along the screw.
This can be achieved either by using a shaft screw or more com-
monly by drilling the hole in the bone the same size as the outer
diameter of the screw thread (gliding hole). One single exces-
sive load applied to the lag screw pulls the screw out of its tight
connection to the bone and the screw "strips". One overload
will permanently negate the function of the screw. This means
that the lag screw technique is not forgiving.
In the conventional AO/ASIF technique, plating was used ex-
clusively to bridge a fracture which had been fixed using a lag
screw. The plate acts like a splint in the same way as an external
splint (plaster cast). The rigid device applied to the bone takes a
major part of the load off the fracture, thus protecting the lag
screw fixation from overload. The term "neutralisation plate"
or better "protection plate" indicates that the plate should pre-
vent overloading of the lag screw and thus stripping.
A plate used without a lag screw acts, when bent, as an elastic
but rigid spring. Any load applied to the plate will always de-
form the plate somewhat, which in turn causes the fracture to
undergo some movement. This then induces callus and resorp-
tion at the fracture site.
Some improvement in the stability achieved using plates may be
attained by applying the plates under tension, which com-
presses and stabilises the fractured bone. When the AO/ASIF
~ technique was first started, the plates were tensioned using the
]. removable compressor. The so-called dynamic compression
·E
(.J
plate (DCP) permits application of compression by taking ad-

=- vantage of a specially designed screw hole. This hole has an in-
-=
; dined surface, which means that the plate compresses the frac-
ture when the screws are inserted in a somewhat eccentric
position. Furthermore, the spherical geometry of the DCP per-
Q.l mits insertion of the plate screws at an angle in order to avoid
==-' fracture lines and improve their function as lag screws.
"§
'ti Thus, while in the conventional AO/ASIF technique plates
~ were not used without lag screws, in the newer techniques of in-
·~ ternal fixation (biological internal fixation) plates are often
== used without lag screws; in these cases, callus formation is not
• 20
an unwanted side effect but the goal of the treatment. The con-
ventional plates are made of a rectangular piece of metal with
screw holes and a rounded undersurface. The disadvantage of
the close contact between the plate undersurface and the bone
surface was damage to the blood supply to bone. Efforts to over-
come this disadvantage led to the development of the so-called
limited contact DC plate (LC-DCP) (Perren et al. 1991). The
LC-DCP permits continued blood supply to the bone and is
much easier to contour than its older counterpart, the DCP.
A nail may also function as a splint, in the same way as a plate.
While the plate is applied to the external surface of the bone, the
nail is inserted inside the bone marrow cavity - a so-called in-
tramedullary nail (i. m. nail). This is an elastic but rigid body
which maintains the shape of the bone to allow the fracture to
heal in a well reduced position. Similar to a splinting plaster cast
or a splinting plate, the splinting i. m. nail does not completely
prevent movement at the fracture site. It resists bending load
well, but is relatively inefficient in resisting torque. This means
that the fragments can rotate about the long axis of the bone, i.e.
a nail does not protect against inward or outward rotation of the
foot. Furthermore, a conventional i. m. nail will not efficiently
resist forces, such as compression, which tend to shorten the
bone. Consequently, only those bone fractures can be well treat-
ed using the i. m. nail which are more or less transverse or short
oblique. To prevent rotation and shortening of multifragmen-
tary fractures, so-called locking bolts are inserted above and be-
low the fracture (Kiintscher, Klemm and Schellmann, Grosse
and Kempf). These locking bolts provide a close connection be-
tween the bone fragments and the nail, thus allowing the i. m.
nail to be used for the treatment of comminuted (multifragmen-
tary) fractures. This technique, called interlocked nailing, has
extended the indications for the i. m. nail.
A new development in i. m. nailing is the "unreamed nail", i.e. a
small solid nail is inserted without first reaming the medullary
cavity. The AO/ASIF unreamed nail is based on experimental
findings in animal research by Klein and has been developed by
Frigg at the AO/ASIF development institute (Klein et al.1990).
The nail is relatively small and does not by itself provide good
fixation. Therefore, it can only be used as an interlocked nail
and only under conditions of limited loading. Due to its interest-
ing biological characteristics, the unreamed nail is especially
well suited for the initial treatment of open fractures.
Another technique to provide splinting of a fracture is the one
using an "external fixator". Here, as with the interlocking nail, a
splint is fixed to the bone using bolts. The splint of the external
fixator is the connecting tube, the bolts are the Steinmann pins
or the Schanz screws. The external fixator provides semi rigid
flexible fixation and is preferentially used in open fractures
where the surgeon does not wish to use massive implants for
reasons of maintaining good resistance to infection. The disad-
21
•
vantage of the external fixator is its pins, which connect the
medullary cavity with the splint outside the body. Since this con-
nection to the outside may precipitate an infection of the
medullary cavity, the latest development replaces the trans-
osseous pin with a forceps-type clamp, which greatly minimises
the amount of damage to the bone (see the reports on the pin-
less external fixator by Swiontkowski, 1992, and Frigg, 1992).
Long spiral fractures were previously treated using "cerclage
wire", i.e. a wire that was put around the bone and tensioned by
applying a so-called quirl. Cerclage wires are well suited for
holding fragments with longitudinal fracture lines together dur-
ing surgical intervention. They do not provide long-term stabili-
ty and only little strength. Therefore, cerclage wires can very
rarely be used alone. The combination of cerclage wire and plas-
ter cast has not offered enough advantages and has therefore
disappeared. Today cerclage is no longer used for permanent
fixation.
Fractures of small bones or of metaphyseal bones are often tem-
porarily fixed using Kirschner wires (K wires) or small pins with
or without threaded pins. Today such pins are mainly used for
temporary fixation preceding stable internal fixation using
plates, for example, for metaphyseal fractures.
The following list provides an overview of the different tech-
niques in relation to the amount of stability achieved.
1. Absolutely Stable Fixation. Absolute stability of fixation, i.e.

no movement of the fracture under dynamic functional load-
ing, is uniquely achieved by the use of compression applied
between the fracture fragments (interfragmentary compres-
sion). The lag screw is a classical example of an implant pro-
viding absolute stability. It produces around 3000 N within
the fracture plane, a force which holds the fragments together
to resist traction as a result of bending and shear produced by
twisting of the bone. The first principle is called stabilisation
by preload; the second, stabilisation by friction. The plate
produces less compression (about 600 N) and the compres-
sion produced acts asymmetrically, i.e. it compresses the frac-
ture on the side near the plate, but tends to open the fracture
at the cortex far from the plate. The nail (AO/ASIF universal
nail and unreamed nail) may cause compression, but it will
only last if locking bolts are placed within cortical bone. The
external fixator allows compression of the fracture, but its ec-
centric placement is the cause of a very asymmetric compres-
sion, which is not usually very effective. The cerclage wire
may produce compression when it is tightened, but once the
quirl is released and bent to avoid protrusion the wire com-
pletely loses pre-tension. K wires and pins do not produce
compression but splint the fragments so that the functional
compression may act upon the fracture surfaces without dis-
placement .
• 22
2. Rigid But Not Absolutely Stable Fixation. Such fixation de-
pends on the use of rigid splints such as large diameter
medullary nails. Functional loading of the fracture splinted
with a rigid splint will produce very little displacement and in
most cases the nail is able to carry body weight.
3. Flexible Fixation. Flexible splint fixation as provided by a
small medullary nail (such as the unreamed nail) maintains
the position of the fracture while allowing intermittent
flexion or twist. Such fixation and fixation using plates with
extensive undercuts to reduce the contact area at the bone-
plate interface are at the basis of biological fixation.
4.4 Glossary
Absolute Stability: The compressed surfaces of the fracture do not displace

under applied functional load. The definition of absolute stability applies
only to a given time and place of observation. While under certain condi-
tions some areas of a fracture do not displace in relation to each other,
other areas of the fracture may do so simultaneously and vice versa. Prac-
tically the only method to achieve absolute stability is to apply interfrag-
mental compression. Compression stabilises by preloading and by pro-
ducing friction (Perren 1972).
Biological Internal Fixation: Also known as biological plate fixation and
biological fixation (Mast et a!. 1989): In internal fixation there is a deli-
cate balance between the degree of stabilisation and that of surgical trau-
ma. The benefits of each must be taken into account. Biological fixation
favours the preservation ofthe blood supply and thus optimises the heal-
ing potential of bone and soft tissues. It provides sufficient stability for
multifragmentary fractures to heal in correct alignment. To protect the
implants from overload, it relies on early biological reaction (callus for-
mation).
If simple fractures are plated, stable fixation to prevent induction of bone
surface resorption is required. In single fractures with closely adapted
fracture surfaces, minimal motion generates high strain,which in turn in-
duces bone surface resorption in contact areas. When locking or nonglid-
ing splints are used for fracture fixation, reliable results are produced by
stability which prevents loosening. Surgical exposure required for stabil-
isation of a simple fracture is limited and therefore less detrimental to the
blood supply and healing of the fracture.
M ultifragmentary fractures and complex fractures are less demanding in
respect to stability. Here, instability produces small amounts of strain
due to (a) larger fracture gaps and (b) distribution of strain over several,
serially located fracture gaps. The operative procedures required for sta-
ble fixation of multi fragmentary fractures are extensive and cause con-
siderable subsequent disturbances to blood supply. Consequently, when
plating a single fracture stability is the prime goal, while in multifragmen-
tary fractures biology takes precedence.
Blood Supply to Cortical Bone (or restoration thereof): Cortical bone
which has been completely deprived of its blood supply for an extended
period of time becomes necrotic. It may be revascularised by the re-
growth of blood vessels without a marked widening of the Haversian
canals (Pfister et a!. 1979) or it may be revascularised by newly formed
Haversian canals. The restoration of previous Haversian canals is a pro-
cess with a marked lag period and is relatively slow (0.1 mm/day, Schenk
23
•
1987). Bone may be revascularised by resorption and replacement with
newly formed, vascular bone (creeping substitution).
Buttress: If trauma results in impaction of a bone (e. g. at the distal meta-
physis of the tibia), a defect remains after fracture reduction. An implant
(plate, external fixator or interlocking nail) then temporarily carries
functional load while it maintains the shape of the bone.
Callus: A reparative tissue made of connective, cartilaginous or bony tissue
(or any combination thereof). Callus formation may be induced by any
irritation due to chemicals (Kiintscher 1970), infection and/or instability
(Hutzschenreuter et al. 1969) and other factors. In internal fixation the
appearance of callus is therefore a little appreciated sign of an unwanted
condition. Callus is, however, always welcome as a repair tissue.
Cancellous Bone: While the shaft of the long bones consists of cortical, i.e.
dense bone, the proximal and distal ends (metaphysis and epiphysis)
consist mainly of a less dense, trabecular bone, cancellous bone. Cancel-
lous bone has per volume a much larger surface area and is, therefore,
more readily receptive to blood supply as well as to osteoclasts for re-
sorption.
Complete Articular Fracture: The articular surface is completely dissociat-
ed from the diaphysis
Complex Fracture: Fracture in which after reduction there is no contact be-
tween the main fragments.
Compression: The act of pressing together. It results in deformation (short-
ening as of a spring) and in an improvement or creation of stability. Com-
pression is used, first, to provide stability of fixation where motion in-
duced resorption must be prevented and, second, to protect the implants
and to improve the efficiency of the implants by unloading them. Un-
loading is achieved through restoration of the load-bearing capacity of
the bone. Any fixation taking advantage of the load bearing capacity of
fragments of a fractured bone can withstand appreciable amounts of load
without mechanical failure or temporary micromotion within the frac-
ture. This is the main reason for using careful reduction and application
of compression. Compression furthermore helps to restore dynamic
loading of the bone fragments, a process for which stable contact of the
fracture fragments is a prerequisite.
If the implant (screw, plate) bridging the fracture is applied under ten-
sion, the fracture focus undergoes an equal amount of compression The
compression is used to help stabilise the fracture. We have not observed
any "magic biological effect" of compression.
Compression Plate: When a plate is applied to produce compression, i.e.
when the plate is tensioned, it is called a compression plate. The tension
in the plate is produced by the application of one plate end to the bone
and by the use of a removable compressor or by eccentric placement of
the screws within so-called compression holes in the DCP or LC-DCP,
for example. The fracture line in between will then be compressed (inter-
fragmental compression). The compression produced by the compres-
sion plate acts outside the fracture, and is therefore asymmetric and pro-
duces high local stress in the cortex immediately below the plate. The
amount of compression produced by the plate is about 60 kp.
Compression Screw: This term does not describe a special implant but
rather the special use or application of an implant. When a screw is ap-
plied to produce compression, i.e. when the screw is tensioned, it is called
a compression screw. The tension in the screw is produced by the com-
bined effect of a screw with a threaded pilot hole and a smooth gliding
hole. When such a screw is tightened, the thread presses the bone frag-
ment against the head of the screw, compressing the fracture line (inter-
fragmental compression). The compression produced by the screw acts
from within the fracture surface and is therefore most efficient. The
amount of compression produced by a 4.5 mm cortex screw is around
250-300kp.
Contact Healing: Healing which occurs between two fragment ends of a
fractured bone at circumscribed places which are maintained in motion-
less contact. The fracture is then repaired by direct internal remodelling .
• 24
Contact healing may also be observed where the gap is only a few mi-
crometers wide.
Cortical Bone, Cortex: The dense bone within the diaphysis (middle part)
of long bones is called cortical bone; the dense shell of the cancellous
bone is called cortex. The two terms are often used synonymously.
Debricolage: A French term to signify the process of mechanical failure of
an internal fixation prior to the onset of solid bone bridging.
Diaphysis: The cylindrical part between the ends of a long bone is called the
diaphysis.
Direct Healing: A type of fracture healing observed in stable internal fixa-
tion. It is characterised by (a) the absence of callus formation specific to
the fracture site, (b) absence of bone surface resorption at the fracture
site and (c) direct bone formation, i. c. without intermediary repair tissue.
Direct fracture healing was formerly called "primary" healing in some
countries. Today we avoid the term primary in order not to grade the
quality of fracture healing. Two types of direct healing are distinguished:
contact healing (see above) and gap healing (sec below).
Dynamisation: The mechanical load can be increased at a certain stage to
enhance bone formation or to promote "maturisation" of the bone. Ex-
amples arc the removal of some screws in plate fixation or the opening of
some clamps in fixation using an external fixator. Early dynamisation,
i.e. dynamisation before solid bridging of the bone, results in stimulated
callus formation. The value of late dynamisation is less obvious.
Epiphysis: The ends of a long bone are called epiphyses. The epiphysis car-
ries the articular component of a long bone.
Extra-Articular Fractures: The fracture does not involve the articular sur-
face, but may be intracapsular.
Far (Trans-) Cortex: The cortex away from the plate is called the far cortex.
It may also be called the trans-cortex. The consequence of a defect within
the far cortex is much more important than that of a defect in the ncar
cortex. The difference is due to the larger lever arm of the far cortex.
Flexible Fixation: Generally, internal fixation according to AO/ ASIF meth-
ods means stable fixation possibly using close adaptation and compres-
sion. Recently, a less stable fixation (flexible fixation using splinting
plates, nails or fixators) has been observed to yield very good results un-
der conditions in which the fragments are well vascularised. Given best
preservation of the viability of the fragments, flexible fixation induces
abundant callus formation. It must be pointed out that the combination
of instability and necrosis may be deleterious.
Fracture: A sudden rupture of a structure which starts whenever the inter-
nal stress produced by load exceeds the limits of strength. Depending on
the type of load- compressive, flexural, torsional, shear and any combi-
nation thereof- a typical fracture pattern can be observed (impaction,
transverse fracture, spiral fracture, avulsion, etc.). The complexity of the
fracture depends mainly upon the amount of energy stored prior to frac-
ture.
Fracture Disease: A condition characterised by pain, swelling and other
signs of dystrophy such as patchy bone loss and stiffness of joints (Lucas-
Championnicre 1907). Fracture disease (synonym, Sudeck's atrophy)
can best be avoided by stable fixation to reduce irritation, by early active
movement and, whenever possible, by immediate or at least partial
weight bearing on the injured limb (All gower 1978)
Gap Healing: The healing process taking place between two fragment ends
kept in stable relative positions with a small gap between the fragment
ends. Gap healing progresses in two phases: (a) the filling ofthc gap with
lamellar bone of different orientation than the bone of the fragments,
and (b) the subsequent remodelling of the newly filled bone from within
the gap into the fragments (plugging) or crossing from one fragment
through the newly filled bone into the other fragment (remodelling)
Gliding Hole: When a fully threaded screw is used as a lag screw, the cortex
under the scrcwhead should not engage. This can be accomplished by
overdrilling the near cortex screw hole to at least the size of the outer
diameter of the screw thread.
25
•
Gliding Splint: A splint (e. g. conventional nail) which allows for axial
shortening. Such a splint offers the possibility of coaptation under condi-
tions of fragment end shortening due to bone surface resorption.
Goal of Fracture Treatment: According to M.E.Mueller eta!. (1963): "To
restore optimal function of the limb in respect to mobility and load bear-
ing capacity." The goal is furthermore to avoid early disturbances such as
Sudeck's atrophy ("fracture disease") and late sequelae such as post-
traumatic arthrosis.
Haversian System: The cortical bone is composed of a system of small chan-
nels (osteons) about 1/10 of a millimetre in diameter. These channels
contain the blood vessels and are remodelled after a disturbance of the
blood supply to bone.
Healing: Restoration of the original integrity. Theoretically the healing
process after a bone fracture would last many years, even after internal
fracture remodelling has subsided. For practical purposes, healing is con-
sidered completed when the bone has regained its normal stiffness and
strength.
Impacted Fracture: A fracture in which the cortex or articular surface is
driven into the cancellous bone.
Indirect Healing: Bone healing as observed in non treated or unstably treat-
ed fractures. Callus formation is predominant, the fracture fragment
ends are resorbed and bone formation results from a process of transfor-
mation of fibrous and/or cartilaginous tissue into bone.
Interfragmental Compression (Effect of): Static compression applied to a
fracture area stabilises the fragments and thus reduces irritation. Bone
surface resorption is then absent. No proof has been found that compres-
sion per se has an effect upon internal remodelling of the cortical bone
(Matteret al.1974).
Interlocking Nail: A nail provides some degree of stability mainly by its
(flexural) stiffness. Since a conventional nail allows the fragments to
slide along the nail, the fracture must therefore provide a solid support
against shortening. For the treatment of complex fractures, the nail can
be interlocked to prevent shortening and rotation.
Lag Screw: The lag screw produces interfragmental compression by com-
pressing the bone under the screw head against the fragment in which the
screw threads are anchored. Interfragmental compression can be re-
duced by wedging the screw threads against the walls of the gliding hole.
Anchorage in the near fragment can be avoided by the use of a shaft
screw. This method is required to maintain efficient compression when
the lag screw is applied through the plate in an inclined position.
Locking Splint: An implant (e. g. plate) acting as a splint, which when some-
what loosened by interface resorption, does not allow coaptation. There-
fore when using a locking splint for fixation of a simple and adapted frac-
ture, interfragmental displacement should be avoided to prevent bone
surface resorption with subsequent biological loosening of the fixation.
Such loosening without possible coaptation may result in a mechanically
induced nonunion. This is a problem after plating, whereas after locked
nailing the mere removal of the locking pins allows for maintenance of the
splinting while gliding along the long axis of the nail is permitted.
Metaphysis: The segment of a long bone located between the end part (epi-
physis) and the shaft (diaphysis). It consists mostly of cancellous bone.
Multifragmentary Fracture: A term reserved usually for extra-articular and
articular fractures which have one or more completely dissociated inter-
mediate fragments.
Near (Cis-) Cortex: Within the plated segment of bone the screws cross two
cortices, the one near the plate is called the near cortex. For this cortex,
the term "cis-cortex" is used as well. In respect to bending, the near cor-
tex contributes little to stability of fixation. When, for example, in a wave
plate application, the distance between the plate and the near cortex is
increased, the bone and the repair tissues gain better leverage.
Neutralisation: An implant (plate, external fixators or nail) which acts
based upon its stiffness is said to neutralise the effect of the functional
load. The implant carries a major part of the functional load and thus
• 26
protects, for example, a screw fixation. It does not actually neutralise but
does minimise the effect of the forces (see protection).
Osteoblast/Osteoclast: Cells that form or destroy bone. The osteoblasts line
a bone surface where bone apposition occurs. The osteoclasts rest in the
Howship lacunae (a small well within the bone surface). They are typical-
ly found at the tip ofthe remodelling osteons (see above).
Overbending (of plate): See Prebending.
Partial Articular Fracture: The fracture involves only part of the joint while
the remainder remains attached to the diaphysis.
Pilot Hole: If a fully threaded screw is to function as a lag screw, the screw is
anchored in the fragment near the tip of the screw within a threaded hole.
This is called the pilot hole. Within the fragment near the head of the
screw, the thread of the screw should not anchor but glide (gliding hole).
A pilot hole is prepared when inserting a Schanz screw or Steinmann pin.
Pin Loosening: The pins of external fixator frames serve to stabilise the
fragments of a fracture. The stability provided depends, amongst other
things, on the contact between pin and bone. If bone surface resorption
at the pin-bone interface occurs, stability is reduced. Pin loosening is less
important in respect to loss of stability but is important in respect to its
deleterious effect on pin track infection.
Prebending of Plate: Exactly contoured plates produce asymmetric com-
pression, i.e. the near cortex is more compressed than the far cortex. The
latter may not be compressed at all. In respect to stabilisation against
torque and bending, the compression of the far cortex is more important
than that of the near cortex. To provide compression of the far cortex the
plate is applied after exact contouring but with an additional bend of the
plate segment bridging the fracture. The bend is such that the mid-sec-
tion of the plate is elevated from the bone surface prior to fixation to the
bone. Prebending is an important tool in increasing stability in small
and/or porotic bones.
Precise Reduction: The exact adaptation of fracture fragments (hairline ad-
justment). It should result in complete restoration of anatomy and opti-
mallate function. It should be noted that overall stability does not de-
pend on precise reduction, but precise reduction more reliably results in
stability and increased strength of fixation.
Preload: The application of interfragmental compression keeps the frag-
ments together until a tensile force exceeding the compression (preload)
is applied.
Protection: While the term neutralisation has often be used in plate and
screw fixation, the term protection should replace it. In reality nothing is
neutralised (which would mean that a force, for example, is counteracted
in its effect by an equal but opposite force). In plate fixation, the plate re-
duces the load placed upon the screw fixation. It therefore protects the
screw fixation from overload.
Pure Depression: An articular fracture in which there is a pure depression
of the articular surface without a split.
Pure Split: An articular fracture in which there is an articular split without
any additional cartilaginous lesion.
Radial Preload: To prevent pin loosening (see above), the contact zone be-
tween the implant and bone can be preloaded, i.e. a static compressive
force is applied. Hitherto, preloading was achieved by applying a perma-
nent bending moment to the pins. Today it is radial preload, i.e. a tight fit
produced by insertion of a pin slightly larger than the drill hole. The ef-
fect of radial preload is to minimise pin loosening and to seal the pin track
such that a possible infection from outside cannot reach the medullary
cavity. The amount of misfit between the hole diameter and the pin diam-
eter should not exceed 0.05-0.1 mm. Such a difference can only reliably
be established using self-cutting tips.
Refracture: A fracture occurring after the bone has solidly bridged, at a
load level otherwise tolerated by normal bone. The resulting fracture
line may coincide with the original fracture line or it may be located re- ~
mote from the original fracture but within the area of bone undergoing "'"'0
changes due to fracture and treatment. G
27
•
Relative Stability: An internal fixation construct that allows small amounts
of motion in proportion to the load applied. This is the case with a fixa-
tion which depends only on the stiffness of the implant (such as a nail
bridging a fracture without exerting compression). It will always show
deformation or displacement which is inversely proportional to the stiff-
ness of the implant. Such motion is always present but harmless in nail
fixation. According to the philosophy of the AO/ ASIF group, plate fixa-
tion is more reliable if motion is prevented. (Callus as a sign of unwanted
instability is then absent.)
Remodelling (of bone): The process of transformation of external bone
shape (external remodelling) or of internal bone structure (internal re-
modelling, or remodelling of the Haversian system).
Resorption (of bone): The process of bone removal includes the dissolution
of mineral and matrix and their uptake into the cell (phagocytosis).
Rigid Fixation: A fixation of a fracture which permits only little deforma-
tion under load.
Rigid Implants: In general, implants are considered to be rigid when they
are made of metal. The implant geometry is more important than the
stiffness of the material. Most implants made of metal are much more
flexible than the corresponding bone.
Rigidity: This term is often used synonymously to stiffness. According to
Timoshenko (1941), it should be used when related to shear (e.g. at the
interface of plate and bone).
Simple Fracture (or single fracture): A disruption of bone (diaphyseal, extra
articular, articular) with two main fragments.
Splinting: The action of reducing the mobility of a fracture based upon a
stiff body being coupled to the bone fragments. The splint may be exter-
nal (plaster, external fixators) or internal (internal fixation plate, i. m.
nail).
Split Depression: A combination of split and depression.
Spontaneous Healing: The healing pattern of a fracture without treatment.
Most often, solid healing is observed but frequently malalignment re-
sults.
Stable Fixation: A fixation which keeps the fragments of a fracture in mo-
tionless adaptation at least for joint movement. While a mobile fracture
produces pain with any attempts to move the limb, stable fixation allows
early painless mobilisation. Thus stable fixation minimises irritation,
which may eventually lead to fracture disease.
Stability of Fixation: This is characterised by the lack of motion at the frac-
ture site (i.e. little or no displacement between the fragments ofthe frac-
ture), while in technical terms stability characterises the tendency tore-
vert to a condition of low energy.
Stiffness: The resistance of a structure to deformation. The higher the stiff-
ness of an implant, the smaller the deformation of the implant, the small-
er the displacement of the fracture fragments, and the greater the strain
reduction in the repair tissue. Reduced but not abolished strain pro-
motes healing.
Stiffness and Geometrical Properties: The thickness affects the deformabil-
ity by its third power. Changes in geometry are therefore much more
critical than changes in material properties. This fact is often overlooked
by non-engineers. Thus, the goal of flexible fixation can be achieved
better by a small change in dimensions than by using a "less rigid" mate-
rial.
Stiffness and Material Properties: The stiffness of a structure depends on its
Young's modulus of elasticity. An increasing Young's modulus affects the
deformation of the material by its first power.
Strain: Relative deformation of repair tissue. Not the motion at the fracture
site but the resulting relative deformation, called strain, is the important
characteristic. As strain is a relative unit (displacement of the fragments
divided by the width of the fracture gap), very high levels of strain maybe
present within small fracture gaps under conditions where the amount of
displacement may not even be visible. Under these conditions invisible
displacement producing strain must be taken into consideration.
• 28
Strain Induction: Tissue deformation- amongst other things- may result in
induction of callus. This is an example of a mechanically induced biologi-
cal reaction. For reactions triggered by strain, such as callus formation
and bone surface resorption, a lower limit of strain, the minimum strain is
to be considered.
Strain Tolerance: Determines the tolerance of the repair tissues to mechan-
ical conditions. No tissue can be formed under conditions of strain which
exceed elongation and cause rupture of the tissue. Above the critical lev-
el, the strain on the recently formed tissues will destroy them once
formed or even prevent their formation.
Strength: The ability to withstand load without structural failure. The
strength of a material can be reported as ultimate tensile strength, as
bending strength or as torsional strength. The local criterion for failure of
a bone or implant is expressed in units of force per unit area, i.e. stress, or
as (equivalent) deformation per unit length, strain or elongation at rup-
ture.
Stress Protection: This term, initially used to describe bone reaction to re-
duced functional load (Allgower et al. 1969) is used today mainly to ex-
press the negative aspects of stress relief of bone. The basic assumption is
that bone deprived of necessary functional stimulation by changing me-
chanical load becomes less dense or strong (Wolff's law, Wolff 1893,
1986). Stress protection is often used synonymously with stress shielding,
i.e. in a purely mechanical sense. It is often used to characterise bone
loss, implying a negative reaction to stress shielding. In respect to inter-
nal fixation of cortical bone, stress protection seems to play a fairly unim-
portant role compared to vascular considerations.
The early bone loss which was hitherto attributed to stress protection can
be explained by a temporary lack of blood supply. The necrotic area is
then remodelled by osteons which originate from the area with good
blood supply. Remodelling goes along with temporary osteoporosis.
Measurements oflate bone loss under clinical conditions of internal fixa-
tion in the human using quantitative computed tomography show very
little bone loss at the time of implant removal ( Cordey et al. 1985).
In summary, bone may react to unloading but this plays a minor role in in-
ternal fixation of cortical bone fractures.
Stress Shielding: If internal fixation relies upon screws and plates, as main-
tained by the AO/ ASIF group, the stability of fixation is achieved by in-
terfragmental compression exerted mainly by the lag screws. Such sta-
bilisation using lag screws is very stable but only provides safety under
functional load in some special situations (long spiral fractures, meta-
physeal fractures, etc.). A plate providing protection (or neutralisation)
is therefore often added. The function of such a plate is to reduce the
amount of peak load applied to the screw fixation. Protection is provided
based upon the stiffness of the plate. The plate shields the fractured and
temporarily fixed bone.
Tension Band: An implant (wire or plate) functioning according to the ten-
sion band principle. The bone carries tensile force when it undergoes
flexural load and the implant is attached to the convex surface; the bone,
and especially the cortex far from the plate, is then dynamically com-
pressed. The plate is able to resist very large amounts of tensile force, so
that the bone in turn can best resist compressive load.
Vascularity: A tissue is vascularised if it contains blood vessels connected to
the main circulatory system. Blood vessels may be shut off temporarily
from the circulatory system. We consider a tissue to be nonvascular if
either there are no vessels, as in cartilage, or the vessels present are not
functioning, for example obliterated by thrombosis.
Wedge Fracture: Fracture with a third fragment in which there is some di-
rect contact between the main fragments after reduction.
29 •
4.5 Principles of Bone Grafting
By C. Colton
In 1668, Job van Meekeren, a Dutch surgeon, filled a cranial de-

fect in a soldier with a portion of a dog's skull. The patient was
promptly excommunicated and later asked for the bone to be
removed. This was not possible as it is said that it had by then in-
corporated.
This would have to be regarded as unusual, as normally only the
patient's own bone- an autograft- will incorporate and not suf-
fer rejection. Bone from another subject of the same species-
an allograft - contains elements which may stimulate an im-
mune response by the recipient (host) but certain methods of
processing the graft can destroy them and allow an allograft to
be accepted, still retaining some power to stimulate new bone
formation. Such a process is freezing at very low temperatures,
this being the basis of most bone banks. MacEwen of Liverpool,
England, was probably the first to use a human bone allograft,
in 1880, to replace the humeral shaft of a young boy, destroyed
by infection.
The function of a bone graft is either to stimulate healing of an
ununited fracture or to fill a bony defect left by trauma, infec-
tion or congenital deficit. The graft acts by providing a "scaf-
folding" for the new bone (osteoconduction) and also by stimu-
lating osteogenesis, or new bone formation (osteoinduction).
Bone containing haemopoietic marrow cells is the best osteoin-
ductive tissue; cortical bone is much less effective. Small frag-
ments of graft are better than solid blocks, because the graft dies
soon after transplantation, but is then revascularised, replaced
and incorporated by the ingrowth of blood vessels from the
graft surface (creeping substitution). The greater the surface for
any given volume, the more rapid the incorporation and healing
will be. It is for these reasons that small chips of the patient's
own cancellous, marrow-containing bone make the best bone
graft material. The commonest sites for harvesting such bone
rr.
~
are the greater trochanter of the femur and the iliac crests. See
Q.. also Sect. 6.18
·oc Specialised bone grafts consisting of blocks of bone together
'i:
=-
'C
with a vascular pedicle are occasionally transplanted using mi-
c crovascular anastomotic techniques. These vascularised grafts
~
are less successful than was originally hoped, and their use is de-
clining.
Q)
=
="
·=-5 4.5.1 Immunology of Bone Grafting
~
(.J
·;;. Any foreign biological material introduced, or finding its way,
=~
into the body may contain chemical components specific to it-
• 30
self which the host recognises as foreign and potentially noxious
(antigens). This may cause the host to produce antibodies which
neutralise or destroy the antigens- the immune response.
An antigen-antibody interaction may simply cause an inflam-
matory state with the local release of histamine, e. g. an allergic
skin reaction to contact with a plant or inflammation of the up-
per respiratory mucous membranes in allergic reactions to
pollen (hay fever). The release of histamine may be greater and
have systemic effects, e. g. anaphylactic shock. Alternatively, as
in tissue grafting, the action of antibodies in attacking the mate-
rial that released the antigen may result in a slower process of
destruction of the graft tissue - a slower immunological rejec-
tion.
The individual's own grafted tissue (autograft) will not, of
course, be seen by the body as a foreign invader and will not ex-
cite such an immune response. On the other hand, an allograft
will be detected by the host's immune system as an invader, by
virtue of the antigenic components of the graft tissue, and is
likely to result in rejection unless the tissue types of the host and
donor are identical or very similar. There are methods, such as
freeze drying, which destroy the antigenic material in allograft
tissue and thereby render it more acceptable to the host's im-
mune system. The deep freezing of bone allografts is the basis
on which bone banks operate.
Nowadays, a greater danger than potential rejection of the allo-
graft is the possibility that the human donor may have acquired
the human immunodeficiency virus (HIV) or some other virus,
such as a hepatitis virus, which the graft then transmits to the
host. When bone is donated to a bank, the donor is usually
screened for HIV and hepatitis virus at the time of donation and
3-4 months later, before the bone graft can be used. The second
test is, of course, not possible in the case of cadaveric material.
Screening protocols vary from centre to centre, and some coun-
tries are stricter than others in the range of tests undertaken on
donors and donated tissue.
4.5.2 Bone Banking
Bank bone is foreign material and may be rejected; this also re-
duces its osteogenic potential. It may also be contaminated with
pyogenic organisms. The risks are of rejection and/or infection.
Bank bone is only used as a last resort, when a graft is needed in
quantities greater than the patient can provide, either because
vast amounts of graft are required as in filling large defects or
extensive spinal fusions, or because the patient's donor sites are
exhausted due to previous failed bone graft surgery. Bank bone
is rarely used in acute fracture surgery.
31
•
4.5.3 Glossary
Allograft: Graft of tissue from another individual of the same species.

Antibody: A substance produced by the host in response to the detection of
an antigen. The antibody is "designed" to attack and destroy the antigen.
Antigen: Component of transplanted tissue which causes the host to mount
an attack on the graft by producing antibodies which destroy the antigen
and in so doing may result in failure of the graft to incorporate.
Autograft: Graft of tissue from the same individual. Same as homograft.
Creeping Substitution: The process of incorporation of a bone graft by vas-
cular ingrowth from the host bed, removal of the dead graft bone by os-
teoclasis and its replacement with living bone by a process of osteoblastic
activity.
Heterograft: Graft of tissue from another individual of the same species.
Homograft: Graft of tissue from the same individual. Same as autograft.
Xenograft: Graft of tissue from an individual of a different species.
4.6 References
Aebi M, Regazzoni P (eds) Bone transplantation. Springer, Berlin Heidel-

berg New York
All gower M (1978) Cinderella of surgery- fractures? Surg Clin North Am
58:1071-1093
Allgower M, Ehrsam R, Ganz R, Matter P, Perren SM (1969) Clinical expe-
rience with a new compression plate "DCP". Acta Orthop Scand [Suppl]
125:45-63
Cordey J, Schwyzer HK, BrunS, Matter P (1985) Bone loss following plate
fixation of fractures? Helv Chir Acta 52: 181-184
Frigg R (1992) The development of the pinless external fixator: from the
idea to the implant. Injury 23 [Suppl3]: 3-8
Hutzschenreuter P, Perren SM, Steinemann S, Geret B, Klebl M (1969)
Some effects of rigidity of internal fixation on the healing pattern of os-
teotomies. Injury 1:77-81
Klein MPM, Rahn BA, Frigg R, Kessler S, Perren SM (1990) Reaming ver-
sus non-reaming in medullary nailing: interference with cortical circula-
tion of the canine tibua. arch Orthop trauma Surg 109/6:314-316
Kiintscher G (1970) Das Kallus-Problem. Enke, Stuttgart
Lucas-Championniere J (1907) Les dangers de l'immogilisation des mem-
bres- fagilite des os- alteration de Ia nutrition du membre- conclusions
pratiques. Rev Med Chir Pratique 78: 81-87
Mast J, Jakob R, Ganz R (1989) Planning and reduction techniques in frac-
ture surgery. Springer, Berlin Heidelberg New York
Matter P, Brennwald J, Perren SM (1974) Biologische Reaktion des
Knochens aufOsteosyntheseplatten. Helv Chir Acta [Suppl]12: 1
Moor R, Tepic S, Perren SM (1989) Hochgeschwindigkeits-Film-Analyse
des Knochenbruchs. Z Unfallchir 82: 128-132
Muller ME, Allgower M, Willenegger H (1963) Technik der operativen
Frakturenbehandlung. Springer, Berlin Heidelberg New York
Perren SM, Klaue K, Frigg R, Predieri M, Tepic S (1991) The concept of
biolgical plating: the limited contact dynamic compression plate, LC-
DCP. Orthop Trauma
Schenk R (1987) Cytodynamics and histodynamics of primary bone repair.
In Lane JM (ed) Fracture healing. Churchill Livingstone, New York
Swiontkowski M (1992) Pinless fixation - Part I: introduction. Injury 23
[Suppl3]: 1-2
Timoshenko S (1941) Strength of materials. VanNostrand, Princeton
Wolff J (1986 [1893]) The law of bone remodeling. Springer, Berlin Heidel-
berg New York
• 32
5 Clinical and Special Assessment
By C. Colton
5.1 Classification of Fractures
The need to classify fractures is an expression of the require-

ment to categorise all the myriad different patterns of failure of
all the bones of the body. Surgeons must somehow speak a com-
mon tongue when they communicate facts about individual
fractures or groups of fractures, either as part of the sharing of
clinical information or for research purposes. Especially for the
latter, the computer has become such a basic information pro-
cessing tool that the "surgical language" must be recognisable
by these devices.
This necessity led to the evolution of the AO classification of
fractures, the brain child of Prof. M. E. Mi.iller. Basically each
long bone group, as well as the spine and the pelvis, is allocated a
number as follows):
- Humerus 1 - Spine 5
- Radius/ulna 2 - Pelvis 5
-Femur 3 -Hand 7
- Tibia/fibula 4 -Foot 8
For the long bones, each is divided into three zones:
1. Proximal metaphyseal/epiphyseal
2. Shaft
3. Distal metaphyseal/epiphyseal
Humerus Radius/Ulna Femur

TiblafFibula
1 2 3
4 Segments
1 proximal
2 diaphyseal
3distal
(4 malleolar)
33 •
Thus a shaft fracture of the femur would fall into group 32 (3 for
femur and 2 for shaft), and by the same token a fracture of the
distal radius at the wrist would be a 23.
An exception is made for the ankle joint mortise with its malle-
oli, because of the special nature of this joint. For it there is a
fourth zone, so that malleolar fracture complexes of the ankle
are group 44 ( 4 for tibia/fibula and 4 for the malleolar zone).
For each zone of each bone the fractures are divided into three
groups- A, B and C, A being the less severe and less difficult to
manage and C being the more serious injuries. It is therefore
logical that a complex intra-articular fracture of the distal
humerus with many joint fragments will be a 13-C injury).
DD-8~ DO
Furthermore, within each A, B or C group there are three addi-

tional subgroups, 1, 2 and 3. The severe elbow fracture of the
type just mentioned would be a 13-C3).
Diagnosis
where? what?
..... I
= ~ 4 Seg~ent
~
~
~.
'-l Sub·
group
"'"'= ~ 123(4) c
~
3 .1 .2 .3
'-l
"'
"'
~ 4 long bones 3(4) segments 3 types 9 groups 27 subgroups
....-;
g
c.
There are even further subdivisions for even more precise cod-
"" ing of fracture types, such as 13-C3.3, a horrendous, multifrag-
't:l
§ mentary joint fracture of the elbow.
-; The spinal classification has not yet been fully decided on, but
·a
1.1
.... there is near agreement on the pelvic and acetabular classifica-

0 tions .
• 34
5.2 General Assessment in Fracture Care
5.2.1 Clinical Diagnosis of Fractures
The clinical features of a fracture are:

- History of trauma
-Pain
- Swelling
- Deformity
- Loss of function
- Tenderness
- Abnormal movement
- Crepius
Not all these features will be present in every case. Clinical sus-
picion of a fracture will be confirmed by the appropriate radio-
graphs. Specialised imaging techniques may be needed to de-
fine precisely the anatomical nature of the injury, knowledge of
which is necessary in order to develop a logical treatment plan.
5.2.2 Assessment of Soft Tissues
The degree of force required to break a bone (the energy trans-

fer) very often also results in damage to the adjacent soft tissues,
including the skin and fat (integuments), the muscles and ten-
dons, the major blood vessels and the nerves. The damage may
be such that the fracture site communicates with the exterior-
an open fracture. Such fractures were previously called com-
pound fractures, the closed fractures without breach of the in-
teguments being called simple fractures. No fracture should
ever be regarded as "simple", and furthermore this outdated
terminology fails to emphasise the importance of the distinction
being drawn, namely that some fractures are "open" to the risk
of infection.
Assessment of the associated soft tissue damage is an integral
and necessary part of the evaluation of any injury.
5.2.2.1 Classification of Soft Tissue Injury
Gustillo and Anderson (1976) graded the wounding of the soft

tissues into:
Grade 1 Small exit wound <1 em in length and clean
Grade 2 Significantly larger wound of the integument without
extensive damage to the underlying muscles, flaps or
avulsions
Grade 3 Open segmental fractures, fractures with major soft
tissue damage or traumatic amputation
35 •
It soon became evident that the definition of grade 3 was too
wide, and Gustillo et al. (1984) subdivided grade 3 into groups
A, Band C, 3C denoting major vascular damage requiring arte-
rial and venous repair.
As the techniques for limb preservation have developed and we
have progressed from almost universal amputation for any sig-
nificant open fracture at the turn of this century, to the complex
reconstructive potential of modern surgery, it has become nec-
essary to categorise soft tissue injuries even more precisely. The
aim of this is to assist in predicting the survivability of a limb.
5.2.2.2 Salvage Versus Amputation
The Mangled Extremity Severity Score (M. E. S. S.) of the Tam-

pa and Seattle trauma groups defines a point scoring system for
injured limbs in such a manner that a score of up to 6 usually
means that attempts at limb salvage are likely to be rewarding,
whereas scores of 7 or more usually indicate the need for ampu-
tation.
In some ways this scoring system is also not ideal and tends to
concentrate on open injuries.lt does not correctly indicate the
severity of a number of injuries in which, even though the in-
tegument is intact and therefore there is technically not an open
fracture, there is massive crushing of the interior of the limb; in
these cases the severity is masked by the intact skin. Tscherne, of
Hanover, emphasised this important consideration and, build-
ing upon his work, the AO coding of soft tissue injury was de-
vised.
In this AO system the letter Cis used if the injury is closed and 0
if it is open. A score of 1-5 (1 indicates normal, except tiny
wounds of minimally open fractures; 2-4 denote increasing
severity and 5 refers to something special) is then allocated to
each of the following:
- Integument: IC (closed) or IO (open)
- Muscle/tendon: MT
- Nerve/vessel: NV
-=e
Q,j
A moderately severe open injury with extensive muscle damage
but no neurovascular injury would be coded I02-MT4-NV1.
Associated with a multifragmentary midshaft fracture of the fe-
"'"'
Q,j mur, this would then be coded 32-C2.1-I02-MT4-NV1. This
"'
'. may appear cumbersome but to a computer it is instantly recog-
"; nisable. All such precisely defined injuries can be analysed as a
·oQJ group, for example to study the results of different forms of
=-
rll management (including amputation rates). Furthermore, it is
-=; international - a sort of musculo-skeletal Esperanto! This is
"; how accurate knowledge is gathered and grows. For more infor-
....
(.I
mation, see Muller et al. (1991 ) .

.5
u
• 36
5.2.3 General Medical Overview of Patient
Although most patients with fractures, whether single or multi-

ple, are young and fit, a significant number may have a pre-exist-
ing pathology, either a medical illness, congenital problems
(such as congenital heart disease) or even the aftereffects of
previous trauma. It is of vital importance that the patient's sta-
tus be viewed as a whole. It is all too easy to become narrowly fo-
cused upon a dramatic injury and to neglect to appraise the
overall status. A careful medical history must be obtained from
the patient, relatives or friends, or from available medical
records. There may be factors, such as those mentioned above,
that will affect resuscitation, anaesthesia, the choice of treat-
ment method and the postoperative medical and nursing care.
5.2.4 Priorities in Polytrauma
Polytrauma, or multiple injury, is a major challenge to the physi-

ology of even the young and healthy. Polytrauma is usually de-
fined on the Injury Severity Score (ISS) scale as more than 16 1.
There is frequently a threat to life, either immediate or poten-
tial. Multiple fractures, especially of the femur, pelvis and spine,
have a profound effect and often lead to life-threatening com-
plications. In the phase immediately after injury, fractures, par-
ticularly open ones, cause major blood loss (a closed femoral
fracture can easily result in 1-1.5 litres of blood being hidden in
a swollen thigh, and a closed pelvic fracture can result in massive
occult haemorrhage of many litres) Sadly, many a patient has
bled to death because the hypovolaemia from a pelvic disrup-
tion has been grossly underestimated. The stabilisation of frac-
tures, even by simple splinting in an emergency, is part of the re-
suscitation. Sir Robert Jones, the father of British orthopaedics,
noted that the introduction of battle-front splinting of femoral
gun shot wounds (using the Thomas's splint) in 1916 during the
First World War reduced mortality from this injury from nearly
80% to15%!
Obviously, also in the immediate postinjury phase, the skilled
management of hypoxia from chest injury is a matter of extreme
urgency, as is the diagnosis and treatment of head injury.
Over the last three decades, it has come to be appreciated that
death in the first few days after injury from adult respiratory dis-
1 The Injury Severity Score scale is a point scoring system which allocates a
score of 0-5 to each of seven body zones or systems, then takes the three
highest scores- the worst injured zones- and adds their squares. The maxi-
mum score would of course be 52 +5 2 +5 2 =75, which would be fatal. The ISS
reflects the extent of the anatomical injury and is widely used to predict out-
come and to audit trauma care.
37
•
tress syndrome (ARDS) and a little later from multiple system
organ failure can very dramatically be reduced by surgical sta-
bilisation of all major fractures in the first 24 h after injury. In-
deed, fracture fixation, internal or external, is regarded as a
continuation of the primary resuscitative measures, and the
seriously injured patient should proceed directly from the emer-
gency room to the operating suite for immediate total surgical
care, all surgical procedures- thoracic, neurosurgical, abdomi-
nal and musculo-skeletal- being undertaken at a single sitting.
With a skilled anaesthetist using good ventilatory control and
modern techniques of monitoring blood gases and intracranial
pressure, the patient is safer under surgery than anywhere else
in the hospital.
5.3 Imaging Techniques
5.3.1 Radiography
As indicated above, after the initial clinical suspicion of a frac-

ture, radiographs confirm (or refute) the diagnosis. Films must
be of good diagnostic quality, taken in at least two planes per-
pendicular to each other (usually antero-posterior and lateral
projections) and the full length of each bone imaged. If a joint is
involved, views centred on the articulation are mandatory. It is
negligent to make management decisions about an intra-articu-
lar fracture on the basis of a full length film of a bone with the
joint at the very edge of the image- as is so often done! In cer-
tain situations, e. g. at the tibial plateaux and the pelvis, oblique
views can help.
Special radiographic projections are helpful in many sites- e. g.
axillary views of the shoulder and acromio-clavicular joints, the
Judet-Letournel iliac and obturator views of the acetabulum
and inlet/outlet films of the pelvic ring. Other techniques of en-
hancing plain radiographs include load-bearing views, such as
the gripping views of the scaphoid and weight carrying views to
elucidate acromio-clavicular joint instability. Stress views for
ligamentous discontinuity are also used at the ankle and some-
times the knee .
• 38
5.3.2 Tomography
Tomography is a radiographic technique which by "trickery"

produces an image of a slice of tissue. The film and the X-ray
source are both moving as the film is shot. The complex trajecto-
ry of each is such that only a thin slice of the body is in focus, the
rest being blurred by the movement. By adjusting the positions
of the film and the source, a series of slices at different depths
through the part being examined can be produced. Their inter-
pretation, however, requires considerable experience ; yet to-
mography can be a great adjunct to standard radiographs in dif-
ficult fractures, for example anterior-posterior (A-P) and
lateral tomography of the tibial plateaux is most valuable.
5.3.3 CT Imaging
This is a complex technique in which an X-ray beam is shot

through the body repeatedly in a transverse direction but aimed
at a different angle each exposure, rather like a sword being
stabbed through from many points around the body, but always
passing through its centre. This produces multiple sets of infor-
mation about the various structures in the path of the beam for
each "stab". These data are then processed by a computer to
construct an image which looks like the cut end of the body after
it has been chopped in half transversely.By further complex pro-
cessing of the data of many slices, three-dimensional images can
be reconstructed , which give invaluable information, for exam-
ple in complicated pelvic and acetabular fractures.
39 •
5.3.4 Magnetic Resonance Imaging
When living tissue is subjected to an intense magnetic field, the

tissue emits faint radio waves (magnetic resonance). The char-
acteristics of these radio emissions vary according to the chemi-
cal composition of the tissue. By passing the patient in graduat-
ed steps through a circular magnetic coil and monitoring the
radio emissions, it is possible to build images of the tissues.
These are very different from radiographic images, and the de-
tection equipment can be tuned in to the radio waves in differ-
ent ways so as to select which tissue is being imaged. Magnetic
resonance imaging (MRI) is very useful for imaging tissues
which do not show on standard X-rays, such as cartilage, menis-
ci, intervertebral discs, and soft tissue tumours. It can even indi-
cate the vascularity of tissues. Very fine resolution images of se-
lected areas can be produced by using surface magnetic coils.
The materials of which AO implants are made, namely 316L
stainless steel and unalloyed titanium, are essentially nonmag-
netic, even after cold working (bending and contouring), and MRI lateral discoid meniscus of the right knee in
therefore will not cause heat effects or become magnetically de- a 14-year old boy. On sagittal and coronal Tl
slices the extent is well visible: increased signal in-
formed by MRI. They will, however, produce artefacts on the tensity (arrowhead) compared with the normal
images, although titanium is less problematic in this respect. medial meniscus (small white arrow). The hyaline
There are methods of modifying the imaging technique tore- normal cartilage (small black arrow) has a normal
signal intensity.
duce this "star burst" effect.
5.3.5 Arthrography
By injecting a radio-opaque dye into a joint cavity and taking

standard X-rays, negative images of the relationships of carti-
laginous and other intra-articular structures can be made. Such
imaging of cruciate ligament damage is an aid in planning recon-
structive surgery. To a certain extent, arthroscopy and high reso-
lution MRI have superseded arthrography. It is extremely valu-
able in the diagnosis of elbow injuries in children and in the
investigation of congenital displacement of the hip. Arthrogra-
phy of the injured adult ankle sometimes aids in the diagnosis of
-=
e
~
lateral ligament ruptures.
"'"'
~
"'"' 5.3.6 Ultrasound

..-;
~
(,1
~ Ultrasound (extremely high frequency sound, inaudible to the
=-
rJl human ear) bounces off tissues to a varying degree, according to
"C
the density of the tissue. This can be used as a safe noninvasive
e
;
investigation of soft tissue abnormalities. It is a highly sophisti-
:5 cated form of the echo-sounding used by ships to scan for under-
U water objects, either the floor of the ocean or submarines .
• 40
Medical ultrasonography, in skilled hands, is useful for detect-
ing effusions of the hip joint and deep haematomas, and of
course, its use in foetal scanning is widely known. Its application
in trauma is currently limited.
5.4 Treatment Options Closed Fractures
5.4.1 Conservative Treatment
Many single, closed and uncomplicated fractures can be treated

by some form of external splintage. The commonest is of course
the plaster of Paris cast - so called as a major source of the gyp-
sum used for plaster was the Mount of Martyrs (or Montmartre)
in Paris. Plaster has been used for centuries in architecture and
art: the technique of fresco painting (see Michaelangelo's ceil-
ing in the Sistine chapel in Rome) consists of plastering the sur-
face then painting on the damp plaster so that the colour seeps
into the material and retains its brightness for hundreds of
years. It was not until Mathysen, a Dutch military surgeon, de-
scribed the plaster bandage in 1854 that modern casting tech-
niques started to develop. Recently, resin-based casting materi-
als have partly replaced plaster of Paris, although nothing beats
it for the ability to mould the setting cast to reduce a fresh frac-
ture.
The concept of functional bracing was reintroduced in the 1970s
by workers such as Mooney and Sarmiento, although the con-
cept was first described by Gooch in 1776! Basically after a
week or so of traditional casting, which always immobilises the
joint above and the joint below a fracture , an articulated brace,
made either of standard casting material or of heat-mouldable
(thermoplastic) sheet plastic, is constructed with joint hinges to
permit joint motion whilst still maintaining control of fracture
position. This has proven to be of particular value in tibial and
lower femoral fractures. It is also of use in the early mobilisation
after internal fixation of certain joint fractures, especially tibial
plateau injuries.
Another form of noninvasive fracture treatment is traction.
This has been traditionally used for femoral fractures, with or
without additional splintage such as Thomas' splint. It is also
sometimes used to gain temporary control of an unstable frac-
ture whilst swelling and soft tissue problems prevent surgery, al-
though external fixation is usually preferred nowadays in this
situation. Traction has to be continued for several months be-
fore femoral fracture union is secured, although attempts tore-
duce this period by functional bracing have met with some suc-
cess when surgery has been inappropriate for various reasons.
41
•
Traction for femoral fractures in the polytrauma patient has
been shown to be associated with a high incidence of potentially
life-threatening complications.
The disadvantages of external casting, and to a certain extent
traction, are that the adjacent joints get stiff, the muscles waste
and the unloaded bones lose mineral and become osteopoenic.
In addition, changes may take place in the vascular and lym-
phatic capillary systems leading to prolonged oedema.
Conservative fracture care is sometimes regarded as being a
simpler alternative to surgical management. To obtain good
functional results from closed fracture treatment requires great
skill and experience, with a constant review of progress and ad-
justment of the splintage; it is not a question of less skill being
required, it is just that the repertoire of necessary skills is differ-
ent from that required for good surgical care.
5.4.2 Surgical Treatment
The surgical treatment of a fracture may be by internal fixation,

directly bridging the skeletal elements with an implant of one
type or another, or by external fixation, in which the skeletal el-
ements are attached to implants, usually away from the fracture
site itself, and external "scaffolding" is used to bridge the space
between these implants (pins or screws projecting out of the in-
tegument).
The disadvantages of surgical fixation are:
1. The potential for the introduction of infection
2. The requirement for specialised surgical skills
3. Instrumentation and the increased need for inpatient facili-
ties
The positive advantages of modern surgical fracture treatment
are that union occurs without deformity in the majority of cases
and that the limb function can be regained more rapidly and, in-
deed, more predictably. The disasters of osteosynthesis usually
result from surgical enthusiasm and bravado, untempered by ba-
sic education and experience. Education in fracture surgery is of
paramount importance in reducing such disasters to a minimum.
Surgical treatment of a fracture should be chosen only when
certain criteria are fulfilled:
1. The predicted outcome will be better than the closed op-
tion.
2. The fracture is amenable to stable fixation.
'; 3. The fixation will permit early functional aftercare.
·;:
4. The patient is fit for surgery.
c.
Q.
r~:. 5. The appropriate surgical skills and experience are available.

"C
; 6. The appropriate surgical facilities are available.
7. The full range of instrumentation to cope with any eventuali-
ty is available.
8. The necessary aftercare can be delivered .
• 42
Any compromise of one or more of these criteria can lead to a
less than optimal result. The greatest disaster is to expose the
patient to the disadvantages of surgery and then fail to reap the
benefits of osteosynthesis- the worst of both worlds.
Tile (personal communication) refers to "the personality of the
fracture problem" which must be assessed before fracture
surgery is undertaken. He means the totality of:
- The nature of the fracture
- The nature of the soft tissues
- The nature of the patient
- The nature of the hospital
- The nature of the surgeon!
There are many different techniques of internal fixation and ex-
ternal fixation of fractures, the principles of which have been
considered in Sect. 4.3 and which will be discussed in detail, as
they are applied to individual fractures, in Chap. 7.
5.5 Treatment Open Fractures
The assessment of the soft tissue injury associated with open

fractures is discussed above.
5.5.1 Soft Tissue Surgery
The surgical management of any open fracture is an emergency.

It is generally agreed that the fracture site must be regarded as
being infected (rather than just contaminated) 6 hours after the
injury and that primary surgery must be undertaken before that
deadline.
The open wound must be extended so that the whole injury zone
can be visualised (Dessault described this in the nineteenth cen-
tury as "debridement", meaning unbridling) and all devitalised
and heavily contaminated tissue removed. Even bony fragments
with no soft tissue attachment must be sacrificed in an open frac-
ture. The injury zone, after debridement and surgical excision,
should then be copiously washed with large volumes of fluid, usu-
Rojczyk 1981 199 open fractures ally Hartmann's or Ringer lactate solution (not normal saline,
Unfallheilkundc 84; 4S8 which is cytotoxic on prolonged contact with tissue); pulsed jet
200 .---- - - lavage is probably even better if available. Rojczyk (1981)
!50 f---+---· showed that swabs taken from the open wounds of 199 consecu-
tive open fractures were sterile in only 49 cases on arrival at hos-
100
pital, but 129 were sterile after surgical wound excision and 168
50
yielded no growth when taken just prior to the conclusion of pri-
o ~~==~------~~------~----
Admission After debridement At surgical exit mary surgery. This demonstrates very clearly the efficacy of good
POSITIVE • EGATIVE surgery in reducing the bacterial population of the fracture site.
43 •
Lacerated major nerves may be considered for direct repair af-
ter skeletal stabilisation, but if in doubt they should be tagged
with a coloured suture material for subsequent reconstruction
or grafting.
Major vessel anastomosis or grafting must be undertaken after
skeletal stabilisation, if necessary to restore viability of the limb.
Although the extensions of the surgical wound debridement
may be closed, the original open wound should never be sutured
primarily, as this greatly increases the chances of infection.
In general, definitive soft tissue cover, either by delayed prima-
ry closure, split skin graft, local soft tissue flap (muscular or fas-
cia-cutaneous) or free tissue transfer by microvascular tech-
niques, should be achieved by 7 days from injury. This is of
course greatly aided by stabilisation of the skeleton.
5.5.2 Skeletal Stabilisation
Stabilisation of the fractures greatly aids soft tissue healing in

open injuries. External cast immobilisation is inadequate be-
cause fracture movement still occurs and risks continuously dis-
turbing the delicate healing tissues. Furthermore, access to the
wounding, even through windows in casts, is grossly inadequate.
It is also difficult to monitor for muscle compartment syn-
dromes with the limb encased.
Most open fractures in the hands of modern fracture surgeons
will be stabilised surgically. Perhaps the commonest method is
the use of external fixation. This, as it were, puts the fracture
"on the back burner" whilst attention is rightly devoted to the
care of the soft tissue injury. The aim is to achieve stable soft tis-
sue cover by 7-10 days from the injury. The external fixatormay
later be changed to another method of skeletal care if mechani-
cal and/or biological considerations so dictate.
The configuration of the external fixator assembly will be cho-
sen according to the needs of the fracture complex but also with
a view to permitting appropriate access to the wounds for what-
ever soft tissue reconstruction is foreseen as possibly becoming
necessary. The planning of the external fixation with these fac-
tors in mind on day 1 is the mark of a good fracture surgeon.
Plating of open fractures is usually safe in skilled hands, provid-
ed the surgical wound care has been impeccable. It is desirable
that the placement of the implants be planned so that they may
-; be covered at the time of surgical exit. Although other methods,
·c~ such as external fixation or intramedullary nailing, are su-
=..
r.r, perseding plating for the tibia and the femur, plating still has
"C
; a place in the humerus and the forearm and for combined
diaphyseal/articular injuries in upper and lower limbs.
Intramedullary nailing of open fractures, once condemned, is
achieving a certain currency. Although there still remain con-
• 44
cerns over the effect of medullary reaming upon the endosteal
blood supply, especially when the periosteal vascularity is com-
promised by the wounding, there are emerging reports of satis-
factory results for reamed nailing of open tibial and femoral
fractures (even Gustillo grade 3 fractures) in very skilled hands.
The advent of unreamed locked nailing, with the theoretical
preservation of the medullary vascularity, has broadened the
appeal of nailing for open fractures.
The "second look" procedure in the first 48 hours after open
fracture treatment is mandatory to check the efficacy of the sur-
gical wound excision, and in extensive wounding, especially
crushing injuries, serial wound excision often proves to be nec-
essary.
5.5.3 General Measures
The general physiological support of the patient is of vital im-

portance and the avoidance of complications in these very seri-
ous injuries is assisted by maintaining the comfort and nutrition-
al status of the injured person. Where an open fracture is part of
a polytrauma complex, then full intensive care, with prophylac-
tic intermittent positive pressure ventilation, nasoduodenal
feeding and intravenous antibiotic prophylaxis, is required.
The whole question of prophylactic measures against throm-
boembolic complications remains unresolved at the present
time. Certainly it is contraindicated in the early stages after mul-
tiple injury, especially with pelvic and spinal fractures, and
where suspected visceral haemorrhage is being treated nonop-
eratively.
Broad spectrum, systemic antibiotic prophylaxis is used for
most open fractures, but must not be regarded as a substitute for
the most immaculate surgical wound excision and aftercare. It is
totally erroneous to believe that a short course of antibiotics can
compensate for fundamental surgical inadequacies.
5.6 Compartment Syndromes
The swelling of muscles after injury, especially crushing injury,

or haemorrhage into a closed osseofascial muscular compart-
ment will rapidly raise the intracompartmental pressure to criti-
callevels. If that pressure exceeds the capillary critical closing
pressure, then muscle ischaemia supervenes. Muscle at body
temperature necroses after 2 hours or more of ischaemia, and
failure to recognise and relieve a compartment syndrome can
result in death of muscle with the consequence of, at least, se-
45
•
vere paralysis of the affected group leading to ischaemic con-
tracture, and even worse, the dead muscle may become infected
and anaerobic organisms can produce life-threatening toxins.
The diagnosis of muscle compartment syndrome is suspected in
any injured patient where the level of pain is more than expect-
ed, with tenderness and induration of the muscle compartment,
loss of active function of the muscle group and pain on passively
moving the distal parts in such a way as to stretch the affected
muscle group. If compartment pressure measuring equipment is
available, emergency monitoring is performed, and if the pres-
sure is suspiciously high, then fasciotomies are most urgently in-
dicated. If such equipment is not available, then clinical suspi-
cion alone is an indication for emergency compartment
decompression. The consequences of "wait and see" are poten-
tially too devastating to justify such a policy. Procrastination
leads to tissue death, not recovery!
5. 7 Glossary
Anaerobic: Refers to any metabolic process which is not dependent upon

oxygen. Anaerobic organisms have a metabolism which can continue in
tissues deprived of oxygen.
Broad Spectrum: Refers to antibiotics which are active against a wide vari-
ety of different organisms.
Endosteal: Adjective from endosteum, which means the interior surface of
a hollow bone- the wall of the medullary cavity.
Energy Transfer: When tissues are traumatised, the damage is due to ener-
gy that is transferred to the tissues. This is most commonly due to the
transfer of kinetic energy from a moving object (car, missile, falling ob-
ject, etc.). The greater the amount of energy transferred to the tissue, the
more extensive the damage.
Fascia-cutaneous: A term describing tissue flaps which include the skin, the
subcutaneous tissues and the deep fascia as a single layer.
Fasciotomy: Cutting the fascial wall of a muscle compartment, usually tore-
lease intracompartmental pressure.
Hypovolaemia: A state where the circulating blood volume is reduced. This
can lead to shock.
Hypoxia: A state where the arterial blood oxygen level is pathologically re-
duced.
Ischaemia: Absence of blood flow.
Multifragmentary: A fracture complex that has more than three fragments
is multifragmentary.
Osseo-fascial Muscle Compartment: An anatomical space, bounded on all
sides by either bone or deep fascial envelope, which contains one or more
muscle bellies. The relative inelasticity of its walls means that if the mus-
cle belly swells, the pressure in the osseo-fascial envelope can build up to
levels which cut off the flow of blood to the muscle tissue, resulting in its
death.
Osteopoenic: An abnormal reduction in bone mass. This may be gener-
alised, as in some bone diseases, or localised as a response to inflamma-
tion, infection, disuse, etc.
Osteosyntesis: A phrase coined by Lambotte to indicate the surgical joining
together of bone fragments, usually by internal fixation. Now also used
to cover external fixation.
• 46
Periosteal: Adjective from periosteum, which is the membrane covering
the exterior surface of a bone. The periosteum plays an active part in the
blood supply to cortical bone, and in bone remodelling.
Polytrauma: Multiple injury. Usually, a person with an Injury Severity
Score of 16 or more is regarded as being multiply injured.
Prophylactic: Preventative.
Segmental: If the shaft of a bone is broken at 2 levels, leaving a separate
shaft segment between the two fracture sites, if is called a "segmental"
fracture complex.
Systemic: Usually refers to a route for drug or fluid administration other
than via the gastro-intestinal tract, by injection.
Toxins: Poisonous chemicals. Some pathogenic organisms release powerful
toxins when they multiply.
5.8 References
Gustillo R, Anderson L (1976) Prevention of infection in the treatment of

one thousand and twenty-six open fractures of long bones. J Bone and
Joint Surg 58 A: 453-465
Miiller ME, Nazarian S, Koch P, Schatzker J (1990) The comprehensive
AO classification of fractures of long bones. Springer, Berlin Heidelberg
New York
Muller ME, All gower M, Schneider R, Willenegger H (1991) Manual of in-
ternal fixation, 3rd edn. Springer, Berlin Heidelberg New York
Rojczyk M (1981) Keimbesiedlung und Keimverhalten bei offenen Frak-
turen. Unfallheilkunde 84:458
Tscherne H, Gotzen L (1984) Fractures with soft tissue injuries. Springer,
Berlin Heidelberg New York
47 •
6 A 0/ASIF Instrumentation
By R. Texhammar
With Contributions by J. Disegi (6.1.1, 6.1.2),
F. Baumgart (6.1.3), and A. Murphy (6.22)
Since 1958 the AO/ASIF group has worked together closely

with biologists, biomechanics and engineers to develop a uni-
form integrated instrumentation providing what is necessary to
solve most problems encountered in the fixation of fresh frac-
tures, pseudarthroses, osteotomies, and arthrodeses. The AO
Technical Commission continuously reevaluates existing in-
struments and implants, supervises new developments, and en-
sures compatibility and high quality. Imitations of AO/ASIF in-
struments and implants, which are sold by nearly all the major
manufacturers of surgical instruments, have contributed greatly
to the spread of the AO method. However, it is important tore-
member that the AO/ASIF and SYNTHES are not connected
with the manufacture of these products and, hence, can assume
no responsibility for their quality.
All of the original AO instruments and implants can be identi-
fied by their engraved symbols, either the current registred
trademark on AO/ASIF instruments and implants or the old
AO symbol, which was used until1969.
6.1 Materials Used for AO/ASIF Instruments

and Implants
6.1.1 Metals Used for AO/ASIF Implants

By J.A. Disegi
6.1.1.1 316L Stainless Steel
AO/ASIF stainless steel implants are produced from implant-

quality 316L stainless steel, which typically contains 62.5%
iron, 17.6% chromium, 14.5% nickel, 2.8% molybdenum, and
minor alloy additions. A low carbon content is specified to en-
sure that the material will be free from susceptibility to inter-
granular corrosion.
AO implant-quality 316L stainless steel meets the metallurgical
requirements established by the American Society for Testing
and Materials (ASTM) and the International Organization for
49
•
Standardization (ISO). The major implant-industry standards
include ASTM F 138 Grade 2 (bar and wire), ASTM F 139
Grade 2 (sheet and strip), and ISO 5832-1 Composition D. AO
implant-quality material must also meet stringent AO/ASIF
internal specifications for composition limits, microstructure
uniformity, and mechanical properties. All implant-quality
material received from approved suppliers is recertified by the
AO producers to provide an extra measure of quality assurance
that metallurgical requirements have been met.
Certain implants, such as cerclage wire or pelvic-reconstruction
plates, are produced from AO implant-quality 316L stainless
steel in the annealed, or softest, condition. This is needed for ap-
plications which demand maximum contourability. The majori-
ty of AO 316L stainless steel implants are produced from cold-
worked, or strengthened, material. Some small-diameter
implants such as Kirschner wires, Steinmann pins and Schanz
screws may be highly cold-worked to resist permanent bending
deformation. AO implant-quality 316L stainless steel is com-
pletely nonmagnetic, regardless of condition. Magnetic reso-
nance imaging may be safely used to visualize hard and soft tis-
sue adjacent to AO stainless steel implants.
Surface treatment known as electropolishing is used for AO
stainless steel implants. Electropolishing consists of applying an
electric current to an implant immersed in a specially formulat-
ed chemical solution under specified conditions of time and
voltage. This treatment decreases the surface roughness of the
implant and provides a good combination of low surface friction
and excellent corrosion resistance. For certain applications,
some AO implants may be shot-peened before electropolish-
ing. The implant surface is subjected to high-velocity impaction
by metallic particles under well-defined conditions. Shot-peen-
ing produces a roughened surface with increased residual com-
pressive stress for enhanced fatigue life.
AO/ASIF Technical Commission consists of general and or-
thopaedic surgeons, material experts, engineers, and manufac-
turing specialists, to provide broad-based expertise in implant
design and development. AO instruments and implants are de-
signed and manufactured to maintain optimum performance.
For this reason, 316L stainless steel implants produced by other
"'
·a=
~ manufacturers should not be mixed with AO 316L stainless
steel implants. The in vivo performance of a mixed implant sys-
'5 tern may be compromised as a result of composition differences,
~ strength variations, and design or workmanship factors.
"0
=
--=
~
=
·=
~
6.1.1.2 Pure Titanium
~
Implants made from commercially pure titanium have been suc-
~
~ cessfully used in clinical practice by the AO group since 1966.
....= AO/ASIF pure titanium does not contain major alloying ele-
• 50
ments, and the metal has a documented history of outstanding
biocompatibility. Clinical experience demonstrates that tissue
adjacent to pure titanium implants is well vascularized with less
tendency toward capsule formation. These biologically
favourable conditions may help to reduce the spread of bacteria
and increase the resistance to infection.
AO/ASIF pure titanium is produced by advanced processing
methods that significantly increase the strength of the material.
Various combinations of strength and ductility are provided to
meet the demands of each specific implant application.
All AO/ASIF pure titanium implants have a special anodized
surface finish that increases the thickness of the protective ox-
ide film. The titanium implants are immersed in a chemical solu-
tion and a known electrical voltage is applied for a specified
time. The specific colour produced depends on the oxide film's
thickness. This is controlled in the anodizing process. Visible-
light diffraction within the oxide film creates a distinct colour.
No pigments or organic colouring agents are present in the an-
odized titanium oxide film. The standard AO anodizing treat-
ment produces the golden appearance that is a distinguishing
feature of AO titanium implants. The titanium anodizing pro-
cess is capable of producing a variety of colours, depending on
the thickness of the oxide film.
Multiple steam sterilization cycles do not significantly change
the appearance of anodized titanium implants. However, fin-
gerprint contamination from skin contact should be avoided in
handling the implants between autoclave cycles. Implant areas
that are touched by hand may show evidence of darkening or
grey discoloration after steam autoclaving. Gloved handling of
titanium implants prevents the discoloration of isolated areas
during steam autoclaving.
Improved biocompatibility, proven functional performance,
and excellent corrosion resistance are important advantages of
AO/ASIF pure titanium implants. Additional clinical benefits
include the absence of allergic reactions to metal and the option
to leave the implant in situ.
6.1.1.3 Titanium Alloys
New biocompatible titanium alloys such as Ti-6Al-7Nb and oth-

er advanced compositions are being evaluated by the AO group
for future implant applications. These titanium alloys offer out-
standing corrosion resistance, excellent biocompatibility, and
higher strength capability than pure titanium. Titanium alloy
implants may be ceramic shot-peened, and either chemically
passivated in nitric acid or anodized as a final surface treatment .
51
•
6.1.2 Materials Used for AO/ASIF Instruments
By J.A. Disegi
6.1.2.1 Stainless Steel
The majority of AO/ASIF instruments are fabricated from

stainless steels which contain a minimum of 12% chromium for
satisfactory corrosion resistance. The selection of a particular
type of stainless steel is based on a number of instrument fac-
tors, such as design and function. Stainless steels used for or-
thopaedic instruments are classified according to composition
and microstructure. The most versatile compositions are the
straight chromium alloys with a martensitic microstructure and
the chromium-nickel alloys with an austenitic microstructure.
Other types of stainless steel known as ferritic or precipitation
hardenable alloys are less common but may occasionally be
used for specialized instruments.
Martensitic stainless steels may contain 12%-18% chromium
and have a medium to high carbon content. They are highly
magnetic and are capable of being heat-treated to a very high
hardness. Specialized heat-treating procedures have been es-
tablished to provide a good balance between hardness and frac-
ture properties. High hardness provides good wear resistance,
and cutting edges retain their sharpness. These alloys may be
used for chisels, bone-cutting forceps, pliers, taps, drill bits,
medullary reamer heads, etc.
Austenitic stainless steels typically contain 16%-18% chromi-
um plus 8%-10% nickel and have a low to medium carbon con-
tent. The alloys may be hardened by cold working but cannot be
hardened by heat treatment. They are generally nonmagnetic,
but some compositions may be slightly magnetic, depending on
specific metallurgical conditions. The austenitic stainless steels
have a lower hardness but better corrosion resistance than the
martensitic stainless steels. Noncutting instruments, such as
drill guides or aiming devices, and components, such as hollow
sleeves, springs, and actuators, are typical examples.
AO stainless steel instruments are typically given a bead blast-
ing treatment as part of the surface finishing operations. Tiny
rl:l
~ beads of aluminia or silica powder are blasted onto the instru-
.S' ment surface to create a lightly textured finish. Bead blasting is
.a
~ followed by controlled electropolishing, to remove any con tam-
~ ination and chemically restore corrosion resistance. Bead blast-
=
"= ing plus electropolishing provide a uniformly corrosion resis-
=
1:':
tant matte surface with the reduced light reflectivity desirable in
-
'=
·= the operating room.
5 All stainless steel instruments manufactured by AO/ASIF pro-
S ducers are capable of passing standardised tests, such as ASTM
2 F 1089 Standard Test Method for Corrosion of Surgical Instru-
"t;;
.5 ments. Specialised corrosion tests in aggressive cleaning and
• 52
disinfecting solutions are also performed by the AO instrument
manufacturers as an added measure of quality assurance. The
useful life of surgical instruments, especially those with cutting
edges, is prolonged when correct care and handling procedures
are followed.
6.1.2.2 Aluminium and Aluminium Alloys
Pure aluminium is a very soft and malleable metal that is used

extensively for AO templates. The templates exhibit a high de-
gree of contourability and are normally anodized a specific
colour for system-identification purposes. The anodizing treat-
ment used for aluminium is different from that used for titani-
um. Aluminium anodizing utilizes a three-stage process that in-
cludes (1) electrochemical oxidation to increase the thickness of
the aluminium oxide film, (2) immersion in a bath containing or-
ganic dye or pigment to produce a specific colour, and (3) chem-
ical treatment to seal the surface for maximum corrosion resis-
tance. Chemical cleaning solutions containing chlorine, iodine,
or certain metal salts may attack the anodized coating. Contact
with strong alkaline cleaners and disinfectant solutions must be
avoided to prevent aggressive chemical attack of the metal.
Certain aluminium alloys may be strengthened by heat treat-
ment and are useful for specific instrument applications. It may
be advantageous to use moderately hard aluminium alloys for
large pelvic instruments or external fixation components when
weight reduction is a factor. Aluminium alloys may also be an-
odized, and the same restrictions apply regarding contact with
chemical solutions.
6.1.2.3 Tool Steel
Various forceps and cutters are manufactured from different

steels, generally used for machine-shop tools. To give these in-
struments the high corrosion resistance necessary for use in
surgery, they are coated with a hard-chrome layer. These instru-
ments thus require special attention when being cleaned and
disinfected. For this reason the majority of such instruments are
now manufactured from stainless steel.
6.1.2.4 Plastics
Various types of plastics are used for certain instrument parts.

They can be divided into two groups, thermosetting plastics and
thermoplastics.
Thermosetting plastics are pressure-setting plastics (e. g. Duro-
plastic) that do not deform at normal sterilizing temperatures,
but that can be damaged or strained by prolonged exposure to
strong disinfectants. The handles of screwdrivers, hammers, pe-
53
•
riosteal elevators, etc, are manufactured from this type of phe-
nol resin.
Thermoplastics are injection-moulded plastics that tend to soft-
en during sterilization, depending on the material and the tem-
peratures used. Polyamid 66, for example, used for the
medullary tube and the spiral hose, softens at 170 oc (approxi-
mately 338 °F). Further thermoplastics are ethylene-propylene
(for the outer tube of the double hose) and acetyl resin (for pro-
tective caps and tube pougs for the external fixator ).
6.1.2.5 Composites
Carbon fibre-reinforced epoxy is used for small and large exter-

nal fixation rods. This composite material provides good axial
frame stiffness, significant weight reduction, and radiolucency
when compared to stainless steel. The rods are resistant to dis-
tortion, delamination, and thermal damage during steam auto-
claving.
Some instrument handles are composed of a linen-impregnated
phenolic composite material known as Tufnol or LE grade phe-
nolic. The handles usually appear light tan in colour when they
are new and have a tendency to become slightly darker in ap-
pearance after repeated handling and multiple steam-autoclave
cycles. This is an aging phenomenon and does not influence the
performance of the instrument. Hot-air sterilization is not rec-
ommended.
6.1.3 The "Mixing" of Instruments and Implants

By F. Baumgart
6.1.3.1 Background
The mixing of implants and instruments from different manu-

facturers leads to risks in hospitals.
"'~ Today, we divide implants into two groups, according to their
~ function:
~ - Temporary implants to support healing after injury or dis-
~ ease, such as implants for internal fixation
"C
; - Permanent implants to replace a living part of the body that
=c
has become dysfunctional due to injury or disease, such as
"; joint replacements
i~ Implants should be able to support the body's biomechanical
5 function as efficiently as did the living parts before injury or dis-
-C
.
ease, or at least as efficiently as is currently possible. Many of
rr.
.E the implants now in use and the special surgical techniques asso-
• 54
cia ted with them have been through lengthy periods of develop-
ment. Since the instruments necessary for implantation form an
integral part of the surgical techniques themselves, the tech-
niques face the risk of failure if parts from various sources are
used or if the instruments and implants do not match.
Since 1958, the Association for the Study of Internal Fixation
(AO!ASIF) has developed a comprehensive system of tempo-
rary implants and instruments for the treatment of fractures and
orthopaedic disorders. This system is compatible within itself
and has been tested worldwide over many years. Clinical results
are continually recorded by the AO/ASIF Documentation Cen-
tre, Davos (Switzerland). The Manual of Internal Fixation
(Miiller et al. 1991) describes the surgical techniques and is used
as the basis for the training of orthopaedic specialists and sur-
geons throughout the world.
The belief that the mixing of implants presents no risk for the
patient, the manufacturer, or the surgeon may possibly be due to
commercial pressures. At all events, it suggests the absence of a
consistent policy of quality assurance. Some of the possible risks
and problems associated with the mixing of implants, instru-
ments, and surgical techniques are described below.
6.1.3.2 An Example
Fractures of the long bones are frequently treated with an AO/

ASIF DCP. This plating system is suitable for 4.5 mm diameter
AO cortex screws, 6.5 mm diameter AO cancellous-bone
screws, and the AO basic instrument set. The surgical technique
is well known (see Miiller et al. 1991 and Sect. 6.5.4, this vol-
ume).
At first sight, the use of a combination of 4.5 and 6.5 mm bone
screws from different manufacturers would seem acceptable
and free from obvious problems. Though it makes no claim to
completeness, the list below outlines some of the causes that can
lead to serious damage, wear, and malfunction of the implant,
and to surgical and functional problems.
Material incompatibility:
- Unsuitable combination of materials: for example, cobalt-
chromium screws should not be used in combination with
stainless steel.
- Nonstandard material: inadequate quality control ofthe raw
material leads to poor overall material quality, corrosion, and
metallosis.
- Insufficient mechanical strength: due to manufacturing pro-
cesses, improper heat treatment, or poor-quality material;
leads to screw failure or corrosion.
Dimensional incompatibility:
- The screw head does not fit the hole in the plate: not spherical
or wrong diameter.
55
•
- The screw's core diameter does not fit the hole in the plate:
this may cause the screw to jam or damage the implant's sur-
face.
- The pitch of the screw thread does not match that of the tap:
the screw jams during insertion or the surgeon may strip the
thread.
- The screwdriver does not fit the recess on the screw head: if
this prevents the use of the wrong screw or screwdriver, it au-
tomatically solves the problem.
- It proves impossible to achieve the maximum angle of about
20 o for lag-screw positioning: this may affect the fixation sys-
tem and prolong surgery.
Incompatible tolerances:
- The screwdriver does not fit the hexagonal recess on the
screw head.
- Unacceptably large deviations in the screw's core diameter:
this may impair the screw's mechanical strength, cause the
screw to jam on insertion, or the surgeon may strip the thread.
The above list deals only with a simple mixture of plates and
screws. The situation becomes rather more complex and critical
when there is a mixture of several implants and/or instruments.
6.1.3.3 Technical Background of Internal Fixation Implants
Implant Materials
The material used for implants is only one element of the sys-
tem, though an important one. The most widely used implant
materials at present are stainless steel and titanium. The stain-
less steel used for implants is a high-purity chromium-nickel-
molybdenum alloy of steel made to national and international
standards.
Mechanical strength is an important material property that can
be influenced by the manufacturing process. Unless the same
manufacturing process is used for both, two dimensionally iden-
tical implants of the same material do not necessarily have the
same mechanical properties.
Standard specifications apply to pure titanium and titanium al-
"'~ loys. These materials are used for implants in internal fixation
&
·• (Sect. 6.1.1.2). The mechanical properties of commercially pure
~ titanium and titanium alloy differ.
~ AO/ASIF conducted a clinical study (Riiedi 1975) on the use of
-=; plates made of pure titanium in conjunction with stainless steel
5 screws. Though no negative clinical effects were observed from
i this combination, a mixture of metals may result in fretting and
i metal sensitivity, reduce biocompatibility, and cause time-de-
~ pendent clinical reactions. Any mixed-metal system increases
- the risks inherent in product liability, a major concern if clinical
~
~ complications occur. Surgeons should therefore abstain from
• 56
mixing or combining standard-quality standardised titanium
and steel implants; the two metals should never be in direct con-
tact with each other, as, for example, in the use of steel screws
with titanium plates. And if there is the slightest suspicion of a
possible allergic reaction to metals, only pure titanium implants
should be used.
Original AO/ASIF implants made of pure titanium have a gold-
coloured finish as a safeguard against the mixing of implants
and the use of unsuitable replacements.
Severe corrosion problems can occur when alloys that do not
meet the standards for implant materials are used in conjunc-
tion with implant-quality stainless steel or pure titanium, espe-
cially if inappropriate manufacturing processes have been used.
Design of Implants and Instruments
The design of implants plays an important part within the sys-

tem of implants, and concerns the technical specifications of
materials and dimensions.
Orthopedic surgery uses vast numbers of bone screws. In gener-
al, without drill bits, screwdrivers, and taps it is impossible to in-
sert screws in cortical bone in a technically clean manner. Other
instruments are also necessary for an exact, safe surgical tech-
nique, such as gauges, drill sleeves, aiming devices, and tissue
protectors. All of these instruments are made to specified toler-
ances, and some but not all are covered by standards.
Manufacturers may vary or reduce the tolerances that these stan-
dards specify. The combination of instruments from different
manufacturers can therefore lead to complications: broken drills
and taps, jammed drill bits, damaged implants. The AO/ASIFin-
strument system is consistent and based on scientific principles;
all components are fully compatible with one another. Use of the
AO system avoids the problems described above.
Orthopaedic surgery makes frequent use of plates in conjunc-
tion with bone screws. In this area, standardization is less far ad-
vanced than for other techniques in current use. For example,
the AO/ASIF DCP, which are used most widely for stable inter-
nal fixation, have not yet been standardised. The holes are spe-
cially shaped to fit the AO/ASIF screws, drill bits, taps, gauges,
etc. (see Sect. 6.5.1.1).
6.1.3.4 Operating Room Staff
The operating-room staff- usually theatre nurses- is responsi-

ble for the organization of the entire armamentarium used for
surgery in the operating theatre. This staff is trained in the use of
the instruments and implants, and is fully familiar with the surgi-
cal procedures.
57
•
The simultaneous use of two different systems increases the risk
of mistakes due to mixing, of improper use and failure of im-
plants and instruments, and of loss of time: broken drills and
taps, poor fit, damaged or broken screws and plates, failure of
internal fixation, etc. Problems inevitably increase in number,
severity, and frequency when systems are mixed, and involve
liability of both surgeon and theatre staff. For a detailed survey
of this problem, see Murphy (1987).
6.1.3.5 Administrative Hospital Staff
Nonmedical hospital staff bears responsibility for the adminis-

tration, planning, purchase, storage, and care of appropriate
and reliable equipment. All these may also have an effect on the
risk to the patient.
6.1.3.6 Final Remark
Every member of the patient-care team has a duty to avoid risk

to the patient.
6.1.4 References
Annual book of ASTM standards, vol13.01, Medical devices

DIN 17443, Stahle fiir chirurgische Implantate, German standard for im-
plant stainless steel
Disegi J (1989) Mixing titanium and stainless steel implants. Personal com-
munication
Harrington Research Centre. Fracture management implant characteriza-
tion study, carried out by the Harrington Research Centre, founded by
AESCULAP Instrument Coorporation
ISO (1980) ISO Standard 5832- implants for surgery- metallic materials-
part 1: wrought stainless steel
Miiller ME, Allgi:iwer M, Schneider R, Willenegger H (1991) Manual of in-
ternal fixation. Springer, Berlin Heidelberg New York
Murphy EK (1987) OR nursing law- interchanging different product com-
ponents; instilling eye drops before patient signs consent. AORN J 47/1:
Perren SM, Geret V, Tepic S, Rahn B (1986) Quantatative evaluation of
biocompatibility of vanadium-free titanium alloys. Biological and
biomechanical performance ofbiomaterials. Elsevier, Amsterdam
Pohler 0 (1988) Unpublished investigation. Personal communication
Pohler 0, Straumann F (1975) Characteristics of the stainless steel
AO/ASIF implants. AO Bull
Radford WJP et al. (1989) Unacceptable variation in the core diameter of
some A 0 type cancellous screws. J Roy Soc Med
Riiedi T (1975) Titan und Stahl in der Knochenchirurgie. Hefte Unfallheilk
3
Sequin F, Texhammar R (1981) AO/ASIF instrumentation. Springer,
Texhammar R (1986) Checklist. A guide to care and maintenance of the
AO/ASIF instrumentation. SYNTHES
• 58
6.2 Classification of AO/ASIF Instrumentation
The comprehensive system of AO/ASIF instruments and im-

plants has been organized into standard sets, which contain the
minimum that the AO group consider necessary for certain pro-
cedures. Instruments and implants not contained in a set are
called supplementary instruments and implants.
Standard sets should be complete at all times, so that a crucial in-
strument or implant will not be missing during surgery. The
number of implants may be decreased in accordance with their
rate of use; however, all lengths and types should be represented.
For the storage of the instruments and implants there is a choice
between three different types of containers:
Sterilization trays in different sizes with the possibility of divid-

ing the tray into compartments for a better overview of the con-
tents. These trays are made entirely of stainless steel and can be
obtained with graphic outlines of the contained items. Holding
pegs for instruments are available. Lids of stainless steel may be
used to protect the contents. The trays can be stacked on their
handles, with or without lids. Advantages: durability, flexibility,
easy overview.
Graphic cases in different sizes made of anodized aluminium.

The original brown cases with beige graphic outlines have been
changed to grey cases with burgundy graphic outlines. The con-
tents are held securely in place with pegs, brackets, and lids.
Corner posts allow stacking with or without lids. Advantages:
easy overview and inventory control.
The old style aluminium cases in a variety of coulors, with differ-

ent insert trays made of stainless steel for the storage of (espe-
cially) implants. This case is less frequently used nowadays due
--e=
to its limited interior space. It has the advantage, however, of =
being rather small and easy to identify because of its colour. ·=~
-.......==
~
...
"'
Q
-
~
=
·=
~
1.1
·r;;
"'
~
0
59
•
6.3 Instruments for Fixation with Large Screws
and Plates
The instruments necessary for the implantation of 4.5 and

6.5 mm screws and plates are called standard instruments and
contained in the basic instrument set, either in a graphic case or
in a sterilizing tray. Old style aluminium cases may still be in use.
Several supplementary instruments are available , which can be
used in conjunction with the standard instruments.
6.3.1 Standard Instruments

TIP ANGLE
Drill Bit Design
The drill bits are designed to provide optimal cutting with as CUTTING EDGE CUTTING EDGE
little thermal damage to bone as possible. Their effectiveness CORNER EDGE
depends upon their wear- and corrosion-resistant material and
FLUTE REAMING EDGE
the design of the cutting edges.
A sharp centre tip ensures a safe first bite on the bone. The cut-
ting edges perform the actual cutting, and their sharpness and
symmetry are crucial to good function. The reaming edges clear
the drill hole of bone debris and have no cutting function. Bone
debris is collected in the flutes and transported away from the
drilled hole. The length of flutes has recently been shortened to
approximately ten times the diameter to increase the strength of
the drill bit.
Table 1. Drill bit data
Standard Total length Effective length Double drill Available drill

drill bit (mm) (mm) sleeve lengtha bit lenght
"' diameter (mm)
=
~
C" (mm)
·='5 3.2 145 120 40mm 80
~ 4.5 145 120 50mm 70
'1; 2.5 110 85 30mm 55
=
~ 3.5 110 85 35mm 50
=
·=-
-e=
2.7 100 75 30mm 45
~
2.0 100 75 22mm 53
1.5 85 60 18mm 42
~
1.1 60 35 14mm 21
2 a Measured from the sleeve end of the size corresponding to the respective
"';
.E drill bit.
• 60
As drill bits are always used in sleeves, only that portion of the
drill bit projecting beyond the sleeve is available to penetrate
bone (Table 1).
There are anatomical sites, for example the proximal tibia and
femur, pelvis, or oblique holes in the metaphysis, where a hole
deeper than that which can be made with the standard drill bit is
necessary. For such instances drill bits of increased lengths are
available.
Standard drill bits are two-fluted and have a quick coupling end
to fit the small air drill. Bits with a triangular end to be used with
a Jacobs chuck adaptor are also available.
Three-fluted drill bits are best used when drilling at oblique an-
gles. Using three cutting edges reduces the likelihood of the drill
skidding off the bone, as it provides better centring of the drill bit.
Cannulated drill bits of different diameters are available to be
used when drilling over a previously placed Kirschner wire (see
Sect.6.6).
Calibrated, three-fluted drill bits are also available. They are
used for drilling in areas where measuring with a depth gauge
may be difficult, e. g. pelvic surgery. The calibration is in 5 mm
increments (see Sect. 6.10).
~
II
II I
I Drill bits should always be used with a drill guide of correspond-
'.\....' ing size. Correct coaxial drilling is thereby ensured without
- r\ . - damaging the soft tissue. Too large a sleeve may result in too
- ----"'!!
large a hole. The drill bit must be stationary (not rotating) when
introduced into the sleeve.
Irrigation during drilling prevents frictional heat. Ringer's lac-
tate solution is recommended.
Damage to the drill bit is most frequently caused by contact with

metal and unnecessary bending forces during drilling. It is es-
sential to inspect drill bits carefully after each use and replace
those which show any damage.
In the standard instrument set the drill bits have the length nec-
essary for screws contained in the basic screw set.
Drill Bit, 3.2 mm

This bit of 145 mm/120 mm (total length/effective length) is
used to prepare the thread hole for 4.5 mm cortex screws,
6.5 mm cancellous bone screws, and malleolar screws.
61
•
Drill Bit, 4.5 mm
This bit of 145 mm/120 mm (total length/effective length) is
used to drill the gliding hole when a 4.5 mm cortex screw is used
as a lag screw to produce interfragmentary compression. If a
6.5 mm cancellous bone screw is to be inserted through hard
(dense) cortical bone at its point of entry, it is necessary to en-
large the near cortex to 4.5 mm to accept the 4.5 mm shaft of the
screw without splitting the bone.
Drill Bit, 2.0 mm

This bit of 100 mm/75 mm (total length/effective length) is used
to pre-drill for Kirschner wires and guide wires in hard bone.
Double Drill Sleeve, 4.5 mm/3.2 mm

This drill sleeve can be used for several functions, thereby re-
placing five previous instruments. The 4.5 mm diameter sleeve
is used with taps and drill bits of that size.The other end accom-
modates the 3.2 mm drill bit. This end also acts as the insert drill
sleeve.The 4.5 mm outer diameter centres the sleeve perfectly
in the gliding hole. It is long enough to reach the far cortex to
drill a coaxial 3.2 mm thread hole in the far fragment for lag
screw fixation of the femur and the tibia. The serrated ends of
both sleeves allow precise placement and prevent slipping if
pushed onto the surface of the bone. This is possible to accom-
plish also through plate holes.
A hole in the handle accepts Kirschner wires up to 1.6 mm diam-

eter. A 4.5 mm cortex screw can be inserted parallel to a previ-
"' ously placed Kirschner wire by sliding the handle over the wire
~
5- and drilling parallel to it.
] The angled handle allows combination with the pointed drill
c..
~ guide.
"C
= Insert Drill Sleeve, 4.5 mm/3.2 mm
--=
~
=
·=
~
This drill sleeve is only necessary for the insertion oflong 4.5 mm
cortex lag screws, i.e. in the lesser trochanter, arthrodeses, pelvic
s
~
-=
fractures etc. The 60 mm long sleeve portion will reach the inner
c: far cortex in large bones for accurate drilling of the thread hole,
...."' where the double drill sleeve end, 3.2 mm is too short .
• 62
This drill sleeve is used to guide the 3.2 mm drill bit when
preparing the thread hole for the 6.5 mm cancellous bone screw.
The other end serves as the tissue protecting sleeve for the
6.5 mmtap.
DCP Drill Guide, 4.5 mm

This drill guide has a neutral (green) drill guide at one end and a
load (yellow) guide at the other.The tip of each guide fits pre-
cisely in the DCP hole. The neutral, green guide accurately cen-
tres the 3.2 mm drill bit in the DCP hole to pre-drill for a screw
in neutral position. The yellow guide places the screw in an ec-
centric load position in the DCP hole for compression, when the
arrow points toward the fracture. Compression of 1 mm in the
long axis of the bone is then achieved (see also p. 85). The
handle can be moved around the guides into an optimal holding
position.
The instrument is disassembled for cleaning. The measurement
4.5 mm in this instance refers to the screw size used.
Note: The DCP drill guide should only be used with DC plates.
LC-DCP Drill Guide, 4.5 mm

This drill guide also has a neutral (green) and a load (yellow)
guide. The tip of each guide fits exactly in the LC-DCP hole.
With this guide the 3.2 mm drill hole is prepared in a neutral po-
sition in the LC-DCP hole, if the arrow of the green guide points
toward the fracture. The eccentric position for compression is
prepared with the yellow guide, also with the arrow pointing to-
ward the fracture. Compression of 1 mm in the long axis is then
achieved. See alsop. 88.
The movable handle has grooves on the undersurface similar to

those of the LC-DCP. The drill guide is taken apart for cleaning.
The "4.5 mm" nomenclature refers to the screw size used.
Note: The LC-DCP drill guide should only be used with LC-DC
plates.
LC-DCP Universal Drill Guide, 4.5 mm

This drill guide is, as the name indicates, a guide for universal
use. It was designed to be used with the LC-DCP, but may be
used with any large plate. It has two sleeves combined on a han-
dle. One sleeve has a 4.5 mm inner diameter to accommodate
the 4.5 mm drill bit and tap. The other side has a sleeve consist-
ing of three components and a spring. These components are
preloaded by the spring in such way that the inner sleeve pro-
trudes at the tip. The sleeve has an internal diameter of 3.2 mm
to accept the 3.2 mm drill bit. Without applying pressure the
63 •
sleeve can be placed in any desired position in the plate hole. An
eccentric position for the load screw is achieved by placing the
sleeve in the far end of the plate hole, away from the fracture.
This will lead to 1 mm displacement of the fragment. Placed in
the near end, a buttress position of the screw is possible. By ap-
plying pressure on the outer sleeve, its rounded tip is pushed
against the inclined cylinder of the plate hole and the neutral
position reached, i.e. at the intersection of the horiontal and
vertical cylindrical profiles of the plate hole. The neutral screw
hole can then be drilled. Because of the round end of the guide,
which corresponds to the undersurface of the screw head, an ex-
act fit between the plate hole and the screw head can be estab-
lished. This is important because it prevents the occurrence of
undesirable torque between the bone segments. It is also possi-
ble to place a screw at an angle and still maintain a congruent fit.
The degree of inclination is limited to angles that provide exact
fit. See alsop. 89.
Large Countersink, 4.5 mm

This countersink is used to cut a recess for the 4.5 mm cortex
screw head, when inserted as a separate lag screw. The 4.5 mm
tip centres the instrument in the pre-drilled gliding hole. By
turning the handle clockwise until the full diameter starts to cut,
a seat for the spherical screw head is prepared. The pressure of
the screw head is distributed over a larger area on the bone,
thereby reducing the concentration of stress. The head also pro-
trudes Jess.
T Handle
The T handle with the quick coupling chuck is used with the 4.5
and 6.5 mm taps. In an emergency it can be used with the large
hexagonal screwdriver shaft as a substitute for the regular
screwdriver. The outer sleeve is pushed forward to allow cou-
pling.
Depth Gauge, 4.5-6.5 mm

The depth gauge measures the drilling depth for the 4.5 and
"' 6.5 mm diameter screws up to 110 mm. The hook has to engage
"g. the opposite cortex before the sleeve is pushed onto the bone or
] plate and the reading made. It is calibrated such that the height
~ of the large screw head is taken into account, and can therefore
~ only be used for the size of screws marked on the depth gauge.
= A new generation of depth gauges with a locking sleeve has
-=
~
.:== been developed to avoid interchanging of the outer sleeves. The
~ depth gauge is disassembled for cleaning.
e
~
-=
=
...
....."'
Note: Measure after countersinking, or through the plate hole,
before tapping .
• 64
Taps- Design
A cortical bone tap is a sharp instrument designed to cut threads
in bone of the same size as the screw's to facilitate insertion. The
tap is sharp and has an efficient mechanism for clearing bone de-
bris into three flutes. These flutes extend from the tip through
the first ten threads, ensuring that debris does not accumulate
and jam the tap. The thread lengths of standard taps correspond
to the most commonly used screw lengths. If longer screws are
inserted, a tap with increased length has to be used (Table 2).
Table 2. Cortex screw tap data
Taps for standard Total length with Thread length

cortex screw quick coupling (mm)
(mm) (mm)
4.5 125 70
3.5 110 50
2.7 100 33
2.0 53 24
1.5 50 20
The long tip and conical run in of the cutting threads facilitate
the tapping procedure. The entire far cortex must be tapped.
The tip of the tap should therefore protrude completely before
returning the tap.
Tapping should be done manually to avoid stripping of the
threads or damage to the soft tissue. Two turns forward and a
half turn in reverse, to clear the threads of debris, is recom-
mended. Taps should always be used with a sleeve to prevent
damage to the soft tissue.
The tap must be cleared of the bone debris between each tap-
ping procedure. The sharp hook or a Kirschner wire can be
used.
The tap for cancellous bone screws is designed with a short and
wide thread of slightly smaller diameter than the screw). It is
normally used to cut the thread in the near cortex only since can-
cellous bone screws can cut the thread themselves in the soft
and spongy cancellous bone.
Note: Power tapping is not recommended. It is easy to damage
the tap, the bone and especially the soft tissues if power tapping
is performed.
Tap for 4.5 mm Cortex Screw

This tap is used to cut the thread in the bone before inserting a
4.5 mm cortex screw, and can also be used for malleolar screws.
It is used for both plate fixation screws and lag screws, since it
has a long thread and a short flute. It combines the function of
the former long- and short-threaded 4.5 mm taps. Threads cut
in the near cortex are protected from damage as the tap is ad-
65 •
vanced through the bone. In the lag screw technique the thread
is cut only in the far cortex. The full diameter of the long, unflut-
ed threaded portion will centre the tap in the gliding hole. This
allows placing the tip of the tap correctly in the thread hole, be-
fore tapping of the far cortex begins. The double drill sleeve end
4.5 mm is used to protect the surrounding soft tissue.
The tap has a quick coupling end and is used with the T handle.
The effective cutting length of the taps in the standard set corre-
sponds to the screw lengths in the basic screw set. Longer taps
are necessary if longer screws are used.
Tap for 6.5 mm Cancellous Bone Screws

This tap is used to cut the thread, usually only in the near cortex
at the point of entry, for 6.5 mm cancellous bone screws. In
young patients the cancellous bone may be quite dense, making
tapping of the entire screw length necessary.
The double drill sleeve end 6.5 mm is used to protect surround-
ing soft tissue. The tap has a quick coupling end and is used with
the T handle.
In straight plates 6.5 mm tapping can only be done through the
slightly larger end holes and has to be done with great care to
avoid damaging the tap.
Note: Never use a power drill with the 6.5 mm cancellous bone
tap.
Large H exagonal Screwdriver

This screwdriver has a hexagonal tip which fits snuggly into the
head sockets of the 4.5 and 6.5 mm screws, allowing easy inser-
tion and removal. It must engage the full depth of the hexagonal
socket of the screw head before it is turned. The shaft has a
groove, which is necessary to take the large screw holding
sleeve. This screwdriver has a shaft 7 mm in diameter and has
replaced the previous screwdriver with a 8 mm diameter shaft.
The latter can not be used with the large screw holding sleeve.
The two ring markings on the shaft indicate the insertion depth
of locking bolts used for universal nails.
Note: Never use a screwdriver with a damaged tip.
"'
·a=
~
Large Screw Holding Sleeve

-=
C.l
This is a self retaining, screw holding sleeve which facilitates in-
~
-== sertion of screws in areas with reduced visibility. It must be used
when removing screws with a smooth shaft, since traction may
--=
CQ
.i= be needed to reverse the screw. It has to be disassembled care-

CQ
fully for cleaning.
e
..-=
~
2
"'
• 66
Large Hexagonal Screwdriver Shaft
This screwdriver shaft has a quick coupling end and can be used
with the small air drill for the insertion and removal of 4.5 and
6.5 mm screws. However, both the final tightening after inser-
tion and the initial loosening prior to removal have to be done
manually. In emergency cases it can be used with the T handle.
The 8 mm shaft diameter does not accept the large screw hold-
ing sleeve.
Articulated Tension Device, 20 mm Span

This device is designed to work in both compression and distrac-
tion modes. It is used in conjunction with plates whenever larger
fracture or osteotomy gaps must be closed (and/or when the
bone is soft, e. g. in porotic proximal femur where the effect of
self-compression is expected to be too small).
For compression, the device is opened fully and the hook en-
gaged in the last plate hole. The foot plate is then fixed to the
bone, usually with a short cortex screw in the near cortex. While
tightening the bolt using the combination wrench, the approxi-
mate compression applied is indicated by coloured rings.
[:;:;:;:::l Yellow ring = 0-50 kp

~ Green ring = 50-100 kp
- Red ring= over 100 kp
For distraction, the device is closed and the hook reversed to fit
0 kp 50 kp 100 kp the small notch at the end of the DC plate. The foot plate is fixed
to the bone with a single cortex screw. By opening the bolt of the
device using the combination wrench the fracture can be dis-
tracted.
Note : The screw used in the foot plate should be discarded, as
the stresses developed may cause it to bend.
Combination Wrench, 11 mm
This wrench is used with the tension device as described above.
It is also used with several other instruments that have bolts or
connections with an 11 mm width across the flats of the nut.
Bending Templates, 120,155, and 210 mm

These templates, made of anodized aluminium, are moulded to
conform to the shape of the bone. The templates then serve as a
model when contouring a plate.
The markings correspond to the plate holes and enable exact
planning of the plate placement. Newly designed templates can
be used with DCP on one side and with LC-DCP on the other
side. The templates are reusable.
67
•
Sharp Hook
The sharp hook is used to check and reduce bone fragments. It
can also be used to free the tap of bone debris or the screw head
of ingrown tissue before removal.
Kirschner Wires, 2.0 mm Diameter

Kirschner wires, 150 mm long, can be used for temporary fixa-
tion or for marking different angles. They can be inserted with a
power drill equipped with Jacobs chuck adaptor. In hard bone it
is recommended to pre-drill with the 2.0 mm drill bit.
6.3.2 Supplementary Instruments
Pointed Drill Guide

This drill guide can be used together with the 4.5 mm end of the ..
4.5 mm/3.2 mm double drill sleeve. It will guide the 4.5 mm drill
bit for the gliding hole to align with a thread hole that has been
prepared before reduction.
Drill Guide with Stop, 4.5/3.2 mm

The drill guide with a stop is used with drill bit 3.2 mm and limits
the drilling depth by adjusting the sleeve length. This is especial-
ly useful in pelvic and spinal surgery.
Socket Wrench
The socket wrench for nuts of 11 mm width can be used to tight-
en the articulated tension device. Because of its universal joint,
its strength is limited and it should not be used to apply strong
forces.
Screwdriver with T Handle

"'
~ This screwdriver can be used to release seized screws from the
·a 4.5 and 6.5 mm group with a large hexagonal socket. It provides
-5
~ even greater turning power than a regular screwdriver.
"C
; Screwdriver with Universal Joint
=
-e
Q ~
~ This screwdriver has a hexagonal tip which fits the large hexago-
~ nal socket of 4.5 and 6.5 mm screws. It may be advantageous to
use in areas with obscured vision, e. g. pelvic or spinal surgery.
=
~ The joint, however, does not allow the generation of strong
.S torque .
• 68
Large Hexagonal Allen Key
This Allen key fits screws with a 3.5 mm hexagonal socket. It
may serve as a reserve.
Wrench,8 mm
This wrench can be used to hold an 8 mm nut, needed in an
emergency for a 4.5 mm cortex screw with stripped threads. The
nut, mounted in the 8 mm wrench, is held against the opposite
surface of the bone while a slightly longer than measured cortex
screw is inserted.
Bending Press
The bending press is used to contour large plates into convex or
concave shapes. It is stable and requires little force for bending.
Before using the bending press, the handle is placed in the neu-
tral position and the jaws adjusted to the plate thickness. The
anvil has two positions; for concave bending the plate is placed
at the front for convex bending it is placed at the back. With the
handle in the neutral position, the knurled knob is turned until
the plate is held firmly between the anvil and the upper jaw.
Bending is made between holes in small increments without ap-
plying too much force until the desired shape is reached. A
bending template serves as a model. While holding the plate
with the press, twisting can be performed with a bending iron.
The bending press has to be disassembled for cleaning. Moving
parts need lubrication. See Sect. 6.22.5.9.
Bending Pliers
The bending pliers have three interchangeable anvils: a large
size for broad plates, a medium size for 4.5 mm DCP and LC-
DCP, and a small anvil for small fragment plates or mandibular
plates. The upper jaw can be rotated to fit the plate cross-section
-convex, concave or flat.
The pliers are adjusted to the plate thickness and to the grip of
the surgeon by turning the knob at the end of the handle. Bend-
ing is performed between the holes and in small increments.
Twisting is possible by placing the plate obliquely in the jaws but
requires care and experience.
Complete disassembly is necessary for cleaning and lubrication.
See Sect. 6.22.5. 9.
69
•
Bending (Twisting) Irons
Bending irons are used solely to twist the plates. The two slots
accept different plate thicknesses. In the newly designed irons,
marked LC-DCP and DCP, the slots have rounded edges to
avoid indentation and possible weakening of plates. The irons
should not be used for bending, since this would cause the plate
to bend at the holes and weaken it.
Small Air Drill

This drill with a double air hose connector and quick coupling
chuck accepts all AO/ASIF drill bits and other instruments with
quick coupling ends. For instruments with triangular ends, a J a-
cobs chuck adaptor can be fitted.
See Sect. 6.21.3
Instruments for R emoval of Damaged Screws

See Sect. 6.19.
6.3.3 Obsolete Instruments
The instruments described below either are no longer manufac-

tured or have been replaced by an improved version. However,
they will still serve their function if undamaged.
Malleolar Countersink, 3.2 mm

This countersink was used with the T handle to cut the recess for
the malleolar screw head. Since malleolar screws are rarely used
in areas where countersinking is necessary, the instrument is ob-
solete. It had a 3.2 mm tip to fit the pre-drilled 3.2 mm hole for
this screw.
Tap Sleeve, 6.5 mm

This tap sleeve has been replaced by double drill sleeve,
6.5 mm/3.2mm
"'~
·8' Straight Drill Sleeve, 4.5 mm/3.2 mm
-=
~
This drill sleeve was used as an insert drill sleeve for lag screw
~
-=; fixation. The double drill sleeve 4.5 mm/3.2 mm and the insert
drill sleeve 4.5 mm/3.2 mm now serve this function.
=
=
~
.... Tap Sleeve, 4.5 mm
=
e This tap sleeve was used as the drill sleeve for the 4.5 mm drill
....2 bit and as a tap sleeve for the 4.5 mm tap. The double drill sleeve
....=
"' 4.5 mm/3.2 mm is the replacement .
• 70
Tap Sleeve, 3.5 mm
This tap sleeve was used as a drill sleeve for the 3.2 mm drill bit.
It has been replaced by the double drill sleeve 4.5 mm/3.2 mm.
Drill Sleeve for Plates, 3.2 mm

This drill sleeve was used as a drill sleeve for plates with round
holes. The double drill sleeve (3.2 mm) now serves this function.
DCP Drill Guides, 4.5 mm

These drill guides, either neutral (green) or eccentric (yellow),
each with a separate handle, have been replaced by the 4.5 mm
DCP drill guide combined on one handle.
Taps with Short and Long Thread, 4.5 mm

These taps have been replaced by the long threaded 4.5 mm tap
with a short flute.
Tension Device, 8 mm Span

This tension device has been replaced by the articulated tension
device, which provides a longer span for compression.
Drill Sleeve for the Tension Device, 8 mm Span

This was the drill sleeve for the tension device, 8 mm.
6.4 AO/ASIF Screws for Large Bone Fractures
Screws are the basic elements for achieving interfragmentary

compression. They can be used as lag screws either individually
or through plates to bring two fragments together under com-
pression. Screws are also used for the fixation of plates to bone.
Screw sizes are named according to the outside diameter of
their threaded portion. The correct screw type, diameter and
length must be selected to correspond to the size, type and qual-
ity of bone.
There are basically two types of screws: cortex screws and can-
cellous bone screws. Cortex screws are designed to be used in
hard cortical bone, mainly in the diaphysis of long bones, but
they may also be used in the pelvis, for example. They are not
self-cutting; the thread has to be cut prior to insertion. 1 The cor-
tex screw may be fully threaded or partially threaded. Malleolar
screws with cortex thread, a shaft and a trocar tip have limited
use in the metaphyseal area, e. g. distal humerus, the trocanteric
area, and sometimes in the ankle, where the bone is rather
dense.
1 A self-tapping 4.5 mm cortex screw is presently being included.
71
•
Cancellous bone screws find their application in the metaphy-
seal and epiphyseal regions, where the bone is softer and
spongy, and the cortex thin. The screws may be fully or partially
threaded, solid or cannulated.
Large AO/ASIF standard screws exist with 6.5 and 4.5 mm
thread diameters, in various lengths. Measurements include
both the tip and the head. The screws are available in both stain- ~
less steel and pure titanium. They may be obtained in standard ~L-----+1
lengths in either a graphic case or in a screw rack for sterilization
trays. Other lengths can be obtained separately.
A screw forceps is used to remove the screws from the rack.
..,l~e
• L ~1
...........
··· ·········......
·······......
··· ···....·······
......... .... ...
···········
··························· ················
Cannulated screws, in diameters 7.0 mm, 4.5 mm, and 3.5 mm,
are discussed in Sect. 6.6.
The large AO/ASIF screws have the following characteristics in
common :
1. Spherical Screw Head. The 8 mm diameter head has a hemi-
spherical undersurface. This ensures optimal annular contact
between the screw and the plate hole, even if it is inserted at an
angle. The hexagonal socket, 3.5 mm in width, enables easy in-
sertion and removal with a hexagonal screwdriver of the corre-
sponding size, without the need to apply axial pressure. It is es-
sential that the socket be free of ingrown tissue before removal
and that the screwdriver fully engage the socket. A damaged
screwdriver would destroy the socket and make screw removal
extremely difficult.
2. A 01ASIF Screw Thread. The design of the screw thread is the
factor ultimately determining the screw's holding power in the
~ material in which it is used. Because the strength of the bone is
.£' ten times less than that of metal, AO/ASIF screws have an
1= asymmetrical buttress thread profile. The flat , broad pressure
~ bearing area gives excellent hold in bone. In hard cortical bone a
1 shallow thread and finer pitch ensure a large contact area and
the best hold. In soft cancellous bone a deep thread and coarse
pitch is necessary to enhance the holding power.
Another prerequisite for optimal holding power is that the
thread hole be prepared to the size of the core (stem) of the
screw and that the threads cut in the bone correspond exactly to
the profile of the screw thread. Tapping is always necessary in
• 72
cortical bone, while in general it is not in cancellous bone, ex-
cept in hard juvenile bone.
3. Core Diameter. The core is the solid stem of the screw from
which the threads protrude. It should not be confused with the
shaft of the screw. The 4.5 mm cortex screw, the 6.5 mm cancel-
lous bone screw, and the malleolar screw made of stainless steel
all have the same core diameter of 3.0 mm. The core diameter of
the large titanium screws, however, differs, i.e. 3.1 mm for the
4.5 mm screw, and 3.2 mm for the 6.5 mm screws. The core size
determines the size of the drill bit used for the pilot hole. The
same size drill bit (3.2 mm) is used to pre-drill the thread hole
for all the large screws.
4. Shaft Diameter. The 4.5 mm shaft screw and the 6.5 mm can-
cellous bone screw each have an unthreaded shaft of diameter
4.5 mm. Pre-drilling of 4.5 mm in the near cortex is therefore
necessary at any entry point in hard cortical bone to avoid split-
ting. The shaft of malleolar screws has the same diameter as the
core, so that pre-drilling of 3.2 mm is sufficient.
6.4.1 Large Standard Screws

4.5 mm Cortex Screws in Stainless Steel and Pure Titanium
These screws are usually used as lag screws or for plate fixation
in the diaphyses of large bones. They are also used as fixation
screws for the tension device or the pelvic reduction forceps.
The 4.5 mm cortex screw is a fully threaded non-self-tapping
screw. Pre tapping of cortical bone is necessary before insertion
of the screw. The thread and the polished surface allow easy re-
moval of the screw, even though hard cortical bone will have
grown between the threads during healing.
The 4.5 mm cortex screw has a smooth tip. It is important for the
holding power of the screw that the threads engage the entire far
cortex. The tip of the screw and one or two threads should there-
fore protrude on the opposite side of the bone. In hard cortical
bone the 4.5 mm cortex screw has a holding strength of approxi-
mately 2500 N (250 kg).
Measurement of the screw length is rounded up rather than
down to ensure optimal holding power. The 4.5 mm cortex
screws are available in lengths from 14 mm to 110 mm in stain-
less steel, and from 14 mm to 140 mm in titanium.
3.2
Important dimensions:
lr
1.75 3.5 - Head diameter: 8.0 mm
- Hexagonal socket width: 3.5 mm
@ - Core diameter: 3.0 mm (titanium3.1 mm)
- Thread diameter: 4.5 mm
- Pitch: 1.75 mm
I
4,5 3.0 80
(3.1Ti)
- Drill bit for gliding hole: 4.5 mmdiameter
~ - Drill bit for thread hole: 3.2 mmdiameter
- Tap diameter: 4.5 mm
73
•
4.5 mm Shaft Screw in Pure Titanium
This screw is a recently developed cortex shaft screw to be used
with the LC-DCP It was used in stainlesss steel for some time as
the locking screw in the universal nails, until the present
stronger locking bolt was introduced.
It is used as a lag screw through a plate or as a free lag screw in
the diaphysis. A cortex shaft screw used as a lag screw produces
a more effective compression than a fully threaded cortex screw,
because the shaft does not accidentally engage in the plate hole
or in the gliding hole. The screw can also be inserted eccentrical-
ly in a LC-DCP hole as a load screw for axial compression. The
shaft portion is five times stiffer and 3.4 times stronger in bend-
ing than the threaded portion. It therefore contributes to the im-
proved axial compression and supplements the self-compres-
sing effect of the plates.
The thread is of the same design as that of the fully threaded cor-
tex screw. Pretapping is necessary before insertion of the screw.
The tip and one or two threads should protrude on the opposite
side of the bone to ensure optimal purchase.
The 4.5 mm shaft screws are available in lengths from 22 mm to
110 mm.The threaded portion of the screw increases from
13 mm to 26 mm in proportion to the overall screw length.
Pretapping of the far cortex prior to insertion is necessary.
3.2
Important dimensions: +
- Head diameter: 8.0 mm c::;:s:: 1.75
3.5
- Shaft diameter: 4.5 mm
- Core diameter: 3.1 mm
~
II @
I
~.5 3.1 ~.5
80
- Pitch: 1.75 mm
- Drill bit for gliding hole: 4.5 mmdiameter c:ss
- Drill bit for thread hole : 3.2 mmdiameter
- Tap: 4.5 mm
I lIt
6.5 mm Cancellous Bone Screws in Stainless Steel
and Pure Titanium I' I
These screws are used only in the metaphyseal and epiphyseal

I I I
ell
areas, with fine trabecular bone and relatively thin cortex.
~ Three different types of screws exist: one with a 16 mm thread
·a' length, another with a 32 mm thread length, and the third fully
'€ threaded. The screws with shafts are designed as lag screws; the
~ fully threaded screw is mainly used as a plate fixation screw
"C
; when the end holes of a plate are located over cancellous bone.
§ The deep and wide threads of the cancellous bone screw ensure
...5
·~ good purchase in the compressed cancellous trabeculae. Tap-
ping is only necessary in the near cortex to allow introduction of
§ the screw. The holding power in the fine trabecular bone is in-
~ creased when the screw itself creates its thread by pressing bone
.S aside. Engaging the far cortex increases the holding power of
• 74
the screw, but is only necessary in porotic bone. However, the tip
is pointed and care must be taken not to damage any structures
on the opposite side of the bone if it is left protruding too far.
The 6.5 mm cancellous bone screws are available in 5 mm incre-
ments in lengths from 25 mm to 110 mm in stainless steel, and
from 25 mm to 150 mm in pure titanium
- Head diameter: 8.0 mm
- Hexagonal socket: 3.5 mm
- Core diameter: 3.0 mm (titanium 3.2 mm)
- Thread lengths: 16and32mm,
fully threaded
- Pitch: 2.75 mm
- Drill bit for thread hole: 3.2 mm diameter
- Drill bit for shaft in hard bone: 4.5 mm diameter
-Tap: 6.5 mm
Malleolar Screw, 4.5 mm

This screw was designed as a lag screw to be used in medial
malleolar fractures, but due to its rather large diameter and
large screw head the smaller cancellous bone screws have taken
its place in this area.The malleolar screw may find its applica-
tion in fractures in the metaphysis, for example in the distal
humerus or in the lesser trochanter. It may also be used in some
pelvic fixations.
The malleolar screw has a smooth shaft and is partially thread-
ed. The trephine tip allows insertion without tapping, and in os-
teoporotic bone sometimes even without pre-drilling the can-
cellous bone. Because of the cortex screw thread profile it has,
however, a rather poor hold.
The malleolar screw is available in lengths from 25 mm to
70 mm. The threaded portion is as the same length as the un-
threaded shaft.
1.75 3.5 Important dimensions:
- Hexagonal socket : 3.5 mm
t 3.0 3.0 - Core diameter: 3.0 mm
(~.5) - Thread diameter: 4.5 mm
- Pitch: 1.75 mm
- Drill bit for thread hole: 3.2 mm diameter
- Tap (rare): 4.5 mm diameter
Washer, 13 mm
This washer has a flat side, which rests on the bone, and a coun-
tersunk side which accepts the screw head. It prevents the screw
head from breaking through the thin cortex in the metaphysis
and epiphysis by spreading the load over a larger area.
75
•
6.4.2 Supplementary Implants
Nut for 4.5 mm Cortex Screw

This nut is an 11 mm flat stainless steel nut with a thread match-
ing that of the 4.5 mm cortex screw and which can be used in the
event of emergency if the hole for the screw has been stripped. It
is held in position with the 8 mm wrench. See above.
Spiked Washer, 13.5 mm

This washer is made of polyacetate with a stainless steel rein-
forcement for X-ray contrast. It is used for reattachment of
avulsed ligaments together with either a 6.5 mm cancellous
bone screw or a 4.5 mm cortex screw. Due to structural changes
in the molecules of the material, it can only be sterilized in auto-
claves at a maximum of 140 oc (270 °F) a few times. Eight hours
are required for cooling and rehardening following sterilization.
Sterilization in EtO (ethylene oxide) is also possible, followed
by a full-cycle aeration. It is therefore recommended to have a
few in stock, separately packaged and presterilized.
6.4.3 Obsolete Implants
Epiphyseal screws had an extra high head to prevent ingrowth

of bone when used in juvenile bone. Since removal still proved
difficult and the fixation of slipped epiphysis was possible with
large cancellous bone screws and a washer, this implant no
longer exists.
6.4.4 Fixation Techniques with Large Screws
Screws are used either as lag screws to achieve interfragmentary

compression or as plate fixation screws. The lag screw tech-
nique should always be used if a screw is to be inserted across a
"'
Qi fracture, even through a plate.
·a=
C"
Principle of lag screw technique: The screw has no purchase in
'5 the near fragment; the thread grips the far fragment only. This
~
;;;; can be achieved with screws that have a shaft or with fully
;j threaded screws. It is the technique of application that deter-
§ mines whether a screw functions as a lag screw. The technique
"';
..... for each individual screw will be discussed below.
=
e
Qi
.....E
rr.
....=
• 76
Positioning of (Cortex) Screws as Lag Screws
Maximal interfragmentary compression is achieved when the

screw is placed in the middle of the fragment and directed at a
right angle to the fracture plane. Any other position would
cause shearing as the screw is tightened, risking displacement of
the fragments. Maximal axial stability is provided by a screw
placed at a right angle to the long axis of the bone. This position,
however, also tends to cause displacement of fragments. There-
fore, in lag screw fixation of a fracture it is best to have at least
one screw at a right angle to the long axis, usually the central
-- '~ ---
------J-~-- ~--- -. -._ - --
one, and one or two perpendicular to the fracture plane.
In diaphyseal bone lag screw fixation alone presents an excep-
• >.
tion. Only in torsional fractures resulting in a long spiral at least

twice the diameter of the bone can lag screw fixation alone give
sufficient stability. If comminution or other factors predisposing
to redisplacement are present, interfragmentary lag screw fixa-
tion must be protected by a plate.
4.5 mm Cortex Screw Used as a Lag Screw
The fully threaded cortex screw is used as a lag screw mainly in

diaphyseal bone where the cortex is thick.
To permit the screw to glide freely through the near fragment, a
so-called gliding or clearance hole is drilled which is equal in
size to the thread diameter. In the far fragment a coaxial thread
hole is drilled which is slightly larger than the core diameter.
The thread hole is then tapped with a tap which corresponds ex-
actly in diameter and thread profile to the screw.
Standard Technique "Outside In"

Step by step procedure:
- The fracture is reduced and held with reduction forceps or
Kirschner wires.
- The gliding hole is drilled in the near cortex with the 4.5 mm
drill bit in the 4.5 mm end of the double drill sleeve (Fig.l ).
- The double drill sleeve is turned around and the 3.2 mm
sleeve inserted into the gliding hole. It is pushed through the
gliding hole until it abuts the opposite cortex.
- The thread hole is drilled in a coaxial direction in the far frag-
ment with the 3.2 mm drill bit (Fig. 2).
- A recess is cut in the near cortical surface with the large coun-
tersink, 4.5 mm (Fig. 3).
77 •
- The screw length is measured with the large depth gauge,
4.5 mm-6.5 mm (Fig.4).
- The thread hole in the far fragment is tapped with the tap for
4.5 mm cortex screws in the 4.5 mm end of the double drill
sleeve. Two turns clockwise and one-half turn counterclock-
wise to free the threads of bone debris (Fig. 5).
- The 4.5 mm cortex screw is inserted with the large hexagonal .': ..• ... ~
screwdriver. Ensure that the screw securely engages the far .. '
cortex (Fig. 6).
Variation: If the far fragment ends in a long narrow spike, where
it is essential to place the screw in its centre, then either the glid-
ing hole or the thread hole can be drilled prior to reduction. This
ensures that the screw can be positioned exactly.
Gliding Hole First Technique "Inside Out"

"'~ Step by step procedure:
I - The gliding hole is drilled from the medullary aspect in the
'5 near fragment with the 4.5 mm drill bit in the 4.5 mm end of
~ the double drill sleeve, keeping in mind the position of the
1 screw in the far fragment (Fig. 1).
~ - The fracture is reduced and temporary fixation applied.
i - The thread hole is drilled in the opposite fragment, using
i
e...= a 3.2 mm drill bit in the 3.2 mm end of the double drill
guide inserted into the 4.5 mm hole (Fig. 2). It is then coun-
~
tersunk, measured and tapped as described above, before in-
.5l serting the screw. 2
• 78
Thread Hole First Technique "Inside Out"
- The thread hole is drilled in the centre of the medullary sur-
face of the far bony spike under direct vision, using the
3.2 mm drill bit and the 3.2 mm end of the double drill sleeve
(Fig.l).
- The pointed drill guide is hooked into the thread hole and
held absolutely centred (Fig. 2).
- The fracture is reduced and temporary fixation applied.
- The 4.5 mm end of the double drill sleeve is pushed into the
cylindrical sleeve of the pointed drill guide until it abuts the
bone. The handles of the 4.5 mm drill guide and the pointed
drill guide are squeezed together to grip the bone and steady
the direction.
- The gliding hole is drilled in the near cortex with the 4.5 mm
drill bit passed through the pointed drill guide assembly, with-
out changing the guide's position (Fig. 3).
- The countersink, the depth gauge, and the tap are then used
as described for the standard technique.
Note:This technique demands that care is taken not to damage
the periosteum when passing the pointed drill guide around the
bone. It is also necessary to hold the tip of the guide absolutely
centred; coaxial drilling of the gliding hole is impossible other-
wise.
The 4.5 mm Cortex Screw Used as a Plate Fixation Screw
Large plates used for fractures in the diaphysis are fixed with
4.5 mm cortex screws. For plate fixation the threads of the cor-
tex screw engage both cortices, or exceptionally only the near
cortex. The appropriate drill guide must be used.
- The fracture is reduced and the plate fixed provisionally to
the bone.
- The thread hole is drilled with the 3.2 mm drill bit in the cor-
rect drill guide through the plate hole and through both cor-
tices.
- The screw length is measured through the plate hole with the
depth gauge, 4.5-6.5 mm.
- Both cortices are tapped with the tap for 4.5 mm cortex
screws in the double drill sleeve, 4.5 mm/3.2 mm.
- The screw is inserted with the large hexagonal screwdriver.
79
•
The 4.5 mm Titanium Shaft Screw Used as a Lag Screw
in a LC-DCP, 4.5 mm
The shaft screw is designed as a partially threaded cortex screw

with a shaft diameter of 4.5 mm. It therefore can be used as a lag
screw which gains purchase only in the far fragment. The
smooth shaft enables gliding in the near fragment. The shaft
screw is used as a lag screw through the plate when it crosses the
fracture.
The "thread hole first technique" is used because this allows ex-
act positioning of the screw in the plate hole.
- The fracture is reduced and the ideal plate site determined.
The plate is fixed with a 4.5 mm cortex screw in each main
fragment.
- The LC-DCP universal drill guide, 4.5 mm is pressed into the
plate hole and the thread hole is drilled through both frag-
ments using the 3.2 mm drill bit (Fig. 1). The LC-DCP drill
guide, 4.5 mm, may also be used.
2
- The screw length is measured with the depth gauge,
4.5- 6.5 mm.
- The thread hole is tapped with the tap for 4.5 mm cortex
screws in the double drill sleeve, 4.5 mm/3.2 mm.
- The 4.5 mm drill bit is used in the double drill sleeve end,
4.5 mm, to prepare a gliding hole in the near cortex (Fig. 2).
- The selected shaft screw is inserted with the large hexagonal
screwdriver (Fig. 3). 3
The 4.5 mm Titanium Shaft Screw Inserted as a Load Screw

in a LC-DCP, 4.5 mm
Since the smooth shaft has the same diameter as the thread, it
provides improved stiffness and strength when the screw is used
as a load screw for axial compression. Either the LC-DCP drill
guide, 4.5 mm, or the universal drill guide, 4.5 mm, can be used
in this procedure.
- The plate is fixed to the bone with a neutral screw in the frag-
ment, which forms an obtuse angle with the fracture surface.
- On the opposite side of the fracture the LC-DCP drill guide,
4.5 mm, is positioned in the plate hole with the arrow pointing
toward the fracture for compression. The thread hole is
drilled through both cortices using the 3.2 mm drill bit. The
hole is now in eccentric position. Variation: The universal drill
guide, 4.5 mm, may also be used. It is placed with its protrud-
ing sleeve in eccentric position in the plate hole, away from
the fracture. The thread hole is then drilled with the 3.2 mm
drill bit.
• 80
- The near cortex is carefully overdrilled with the 4.5 mm drill
bit in the double drill sleeve end, 4.5 mm.
- The screw length is measured.
screw in the double drill sleeve end, 4.5mm.
- The selected 4.5 mm shaft screw is inserted with the large
hexagonal screwdriver. Interfragmentary compression is
achieved.
The 6.5 mm Cancellous Bone Screw Used as a Lag Screw
The partially threaded cancellous bone screw with a smooth

shaft has beendesigned for use as a lag screw. The 4.5 mm diam-
eter shaft ensures gliding in the near fragment. The threaded
portion, 16 mm or 32 mm in length, should have purchase in the
far fragment only, whereby the size of the far fragment deter-
mines which thread length is chosen. A 32 mm thread provides a
better hold. Lag screw fixation can be used either separately or
through a plate hole.
- The fracture is reduced and temporarily held with Kirschner
wires or pointed reduction forceps.
- The thread hole is drilled through the entire depth of the
bone with the 3.2 mm drill bit in the 3.2 mm end of the double
Cit)'i';A;"''f&l'l drill sleeve, 6.5 mm/3.2 mm (Fig.1 ).
- In hard juvenile bone the near cortex may need to be over-
drilled to 4.5 mm to accept the shaft.
4.5-6.5 mm (Fig. 2).
- The near cortex is tapped with the tap for 6.5 mm cancellous
bone screws in the 6.5 mm end of the double drill sleeve,
6.5 mm/3.2 mm (approx. 10 mm) (Fig. 3).
- In very hard juvenile bone it is recommended that the entire
thread hole be tapped.
- The screw is inserted with the large hexagonal screwdriver
(Fig.4).
3 Note: A washer is often needed to prevent the screw head from
sinking into the bone. The flat side of the washer is placed on the
bone.
81
•
The Malleolar Screw as a Lag Screw
The malleolar screw is primarily used for lag screw fixation in

the metaphysis. Its shaft allows gliding and the 4.5 mm cortex
thread should have purchase only in the far fragment.
- The fracture is reduced and temporarily fixed.
- The thread hole is drilled with the 3.2 mm drill bit in the
3.2 mm end of the double drill sleeve, 4.5 mm/3.2 mm.
4.5-6.5 mm
- If necessary, the bone is tapped with the tap for 4.5 mm cortex
screws in the double drill sleeve end, 4.5 mm.
- The screw is inserted with the large hexagonal screwdriver.
6.4.5 AO/ASIF Instruments for Insertion and Removal

of Large Screws
Instruments for the insertion of 4.5 mm cortex screws as lag

screws r
I
Instruments for the insertion of 6.5 mm cancellous bone screws Instruments for large screw removal
• 82
6.5 Plates for Large Bone Fractures
The large AO/ ASIF plates have been designed for the fixation
of certain fractures in large bones, i.e. humerus, pelvis, femur
and tibia. They are also referred to as large plates because they
are fixed to the bone by means of the large screws described in
Sect.6.4.
Each plate has a name, which either describes the design of the
plate (e. g. semitubular plate), the part of the bone on which it is
used (e. g. lateral tibial head plate) or a very special feature of
the plate (e. g. Limited Contact-Dynamic Compression Plate or
LC-DCP). Plates can also be referred to by the function they
fulfil in a particular fixation, e. g. a tension band plate, neutral-
ization or protection plate, compression plate (see Sect. 6.5.4).
These functions, however, can be performed by different
plates.
There are three main groups of large plates: the straight plates,
the special plates and the angled blade plates. Of these, the
straight plates are used mainly in the diaphysis, the special plates
in the metaphyseal and epiphyseal areas and the angled blade
plates in the proximal and distal femur. In this section only
straight and special plates are discussed. Angled blade plates
are described in Sect. 6.8.
Most plates and screws are available both in stainless steel and
in commercially pure AO titanium. High quality stainless steel
has been the standard material for implants for a long time. It
offers good mechanical strength, together with excellent ductil-
ity. This steel is available in different degrees of strength, which
allows the choice of a material corresponding to the function of
the implant. Although highly purified and of an optimized
chemical composition, stainless steel may still show local corro-
sion and eventually pitting corrosion, which may eventually
cause a tissue reaction.
The attractive biological characteristics of commercially pure
AO titanium (p.Ti), when cold worked to high strength, has
therefore made this an implant material of choice, especially for
patients suffering from metal allergy. Due to its mechanical
properties, the handling of pure titanium plates, for example,
contouring, feels somewhat different from that of stainless steel
plates. Whatever material is chosen for plates, though, it is rec-
ommended that the same material be used for screws. See also
Sect.6.1.1
83 •
6.5.1 Standard Plates
The standard plates may be obtained in either a graphic case or

a sterilizing tray.The old aluminium cases can also be used for
storage.
6.5.1.1 Straight Plates
DCP,4.5mm
The term DCP stands for dynamic compression plate. The term
DCP plate is therefore incorrect. It is nevertheless used since
DCP is a registered term rather than the descriptive expression.
The DCP was developed to improve the former plating tech-
niques with round hole plates. Over the years the DCP has been
used for successful fixations of many fractures, especially in the
long bones. The special geometry of the plate hole allows for
self-compression and a congruent fit between screw head and
plate hole at different angles of inclination. The plate can thus
fulfil different plate functions, e. g. compression plating, tension
band plating, neutralization (protection) plating, and buttress
plating. See Sect. 4.2
Plate Hole and the "Spherical Gliding" Principle

The plate hole can best be described as a part of an inclined and
horizontal cylinder in which a sphere can be moved downwardly
and horizontally to the intersection of the two cylinders. The
f)
•.L . _ =
@
:;------ r------:r> ~f{
:,__~ ___ -
~/
cylinders represent the plate hole and the sphere the screw
head. Axial compression between fragments can be achived by
using this feature of the plate holes.
A screw placed at the inclined plane, i.e eccentrically (load posi-
tion), will move the underlying bone horizontally in relation to
the plate until the screw head reaches the intersection of the two
cylinders. At this point the screw has optimal contact with the
hole, ensuring maximal stability. The horizontal "cylinder" pre-
vents jamming as well as undesired distraction. A 4.5 mm cortex
screw can be placed in three different positions in the plate hole :
'10
eccentric (or load) position, neutral position, and buttress posi-
·a-5
~
tion.
All holes in the DCP embody the spherical gliding principle.
~
"CC
; The DCP Drill Guide, Neutral and Load
...=
-e=
0 A special drill guide is necessary for the correct placement of
~ the screws.The two ends connected on a handle fit exactly in the
plate holes.
-.s..=
~
'10
• 84
The neutral, green end of the DCP drill guide is used when
drilling for a screw in the neutral position, that is, at the intersec-
tion of the two cylinders. A minimal movement of 0.1 mm in fact
occurs when this guide is used. The neutral DCP drill guide is
the one most frequently used.
The load, yellow DCP drill guide allows eccentric drilling, plac-
ing the screw in a load position. The little arrow on the top must
CID / point toward the fracture, because when the screw is driven
~~
home, it is displaced 1.0 mm horizontally. This guide is used only
to achieve axial compression once the fracture has been
O,lmm
anatomically reduced and fixed with at least one screw in the op-
posite fragment.
The buttress position of a screw is obtained by using the 3.2 mm
side of the double drill sleeve. The sleeve is placed snugly at the
inner limit of the plate hole near the fracture. This position is
needed when the plate is being used to prevent collapse of a
fracture reduction, i.e in comminuted or metaphyseal fractures.
Advantages of the DCP Design

' II
, I,
\If The DCP holes offer several advantages:
- Inclined insertion of the screw with hemispherical screw head
- is possible up to an angle of 25 o longitudinally (Fig. 1), 7 o
I
sideways (Fig. 2).
/ :21s• \ - Placement of a screw in neutral position without the danger
of distraction of fragments.
,II - Insertion of a load screw into the hole positioned most
~
favourably for a given fracture. All holes permit compression
2 (Fig. 3).
!.,.I I
( ~
~I
I'\. 1\ \. ./ '-'\. d::Ll
_,_
It
~
85 •
- Usage of two load screws in the main fragments for axial com-
pression. After one screw has been inserted in load position in
each main fragment, producing 1 mm displacement, the hori-
zontal track in the hole still permits a further 1.8 mm of "glid-
ing" (Fig. 4). A second load screw can therefore be inserted in 4
the next hole without being blocked by the first screw. The
first screw, however, must be slightly loosened before the fur-
ther 1 mm compression can be produced by the second screw
(Fig.5).
~5
- Compression of several fragments individually in comminut-
ed fractures) (Fig. 6).
- Application as a buttresss plate in articular areas by inserting
the screws in the buttress position.
~6
Before a DCP is applied to achieve axial compression, the plate
must be contoured or pre bent and the fracture anatomically re-
duced with the fragm ents in contact. One fragment is fixed with
a screw in neutral position. A screw inserted in a load position in
the other fragment can then produce axial compression of
50-80 kp. If further impaction is needed, a second load screw
can be inserted in either fragment. A maximum of two load
screws can be used in each fragment. This means a compression
of 22 mm. In such cases, however, use of the articulated tension
device is recommended
®®
Narrow DCP, 4.5 mm

This plate is designed to be used on the tibia, and sometimes on
the radius or ulna of a large patient. The size of the bone deter-
mines which size plate is used. The DCP is fixed to the bone with
4.5 mm cortex screws, but 6.5 mm cancellous bone screws can
be inserted in the end holes if this part of the plate is over the
metaphysis.
~ Both ends of the plate have a notch on the underside for the
;. hook of the tension device. The middle part, with a wider space
] between the holes and therefore stronger, is placed over the
~ fracture.
'C The DCP, 4.5 mm is available with 2-16 holes.
=
••
~
= Important dimensions:
·=....
....
~
- Profile: see figure
3.6mm
=
Q,l
5
- Thickness:
- Width : 12 mm
....e
..=
"'
- Hole spacing:
- Hole length:
16and25 mm
8.5mm
• 86
Broad DCP, 4.5 mm
This plate is designed to be used for fractures in the diaphysis of
femur and humerus. It is both thicker and wider than the narrow
DCP and therefore not suitable for use in smaller bones.
The plate holes are staggered to prevent longitudinal fissuring
of the bone. The plate is fixed with 4.5 mm cortex screws in the
diaphysis. All end holes accept the 6.5 mm cancellous bone
screws if the plate is fixed to cancellous bone. A notch at each
end hole allows use of the tension device.
The broad DCP is available with 6 to18 holes.
- Profile : see figure
- Thickness: 4.5mm
- Width: 16 mm
- Hole spacing: 16and25 mm
- Hole length: 8.5mm
LC-DCP, 4.5 mm in Pure Titanium
The LC-DCP (limited contact DCP) is a further development of

the DCP. Extensive studies led to the change in design and to the
use of titanium as implant material. (See also Sect. 6.1.1.) The
LC-DCP is used for the same indications as the DCP, but the im-
proved design offers additional advantages.
Design Features
- The evenly distributed undercuts reduces the contact area be-
tween bone and plate to a minimum. This significantly re-
duces impairment of the blood supply of the underlying corti-
cal bone and consequent demineralisation beneath the plate.
The undercuts also allow for the formation of a small callus
bridge, which increases the strength of the bone at a very crit-
icallocation.
I I
- The enlarged cross section at the plate holes and the reduced
cross section between holes offer a constant degree of stiff-
ness along the long axis of the plate. No stress concentration
occurs at the holes when the plate is exposed to a bending
load or during the contouring.
- The trapezoid cross section of the plate results in in a smaller
contact area between plate and bone. A broad and low lamel-
la along each side of the plate is formed , which is less likely to
be damaged at plate removal.
- The plate holes are uniformly spaced, which permits easy po-
sitioning of the plate. The holes have the same length as the
DCP holes (8.5 mm).
87 •
- Symmetrical spherical gliding holes: the basic principle of
spherical gliding of the screw head in the plate hole is pre-
served, but augmented. Both ends of each plate hole offer the
gliding possibility, which means more versatility in use. The
holes allow 1.0 mm displacement of the fragment if a load
screw is inserted.
- Undercut plate holes: undercut at each end of the plate hole

allows 40 o tilting of screws both ways along the long axis of
the plate. Lag screw fixation of short oblique fractures is
thereby possible. Screws can be tilted ±7 o in the transverse / .'\
plane. Furthermore, the undercuts reduce the contact area
between plate and bone even more.
- The end holes of the plate allow use of the articulated tension
device if further compression is necessary, i.e. in fractures of
the femur with a wide gap.
Before applying a LC-DCP, the plate must be contoured or
pre bent and the fracture anatomically reduced.
The LC-DCP, 4.5 mm, is fixed to the bone with 4.5 mm cortex
screws and 4.5 mm shaft screws, or in the end holes with 6.5 mm
cancellous bone screws. The 4.5 mm screws can be inserted in
three different positions: neutral, load, and buttress. For this
pupose special drill guides have to be used, either the LC-DCP
drill guide, 4.5 mm, or the universal drill guide, 4.5 mm.
LC-DCP Drill Guides

The LC-DCP drill guide, 4.5 mm, is similar to the DCP drill
guide, 4.5 mm, in that it has a neutral (green) and a load (yellow)
guide combined on a handle. The inserts will only fit this special
8
(Q)
"'~
~~
handle, which has been designed with the same undercuts as the
·f plate to distinguish it from the DCP drill guide handle. The
-5 green neutral guide places the screw in a neutral position if the
~ arrow points toward the fracture. Turned 180 o , the arrow point-
=
"C
ing away from the fracture, a buttress position is obtained. The
=
C':l
yellow load guide places the screw in an eccentric position for
·=-; compression, when the arrow points toward the fracture. The
C
~
displacement is 1.0 mm.
5 Because of the spherical end of the guides, they have a congru-
S ent fit in the plate hole, also when tilted 40 o in the longitudinal
.S"' and ± 7 o in the transverse plane.
• 88
The LC-DCP universal drill guide, 4.5 mm, has two different
sleeves combined on a handle. One sleeve has an inner diameter
of 4.5 mm and is used with the 4.5 mm drill bit and the tap for
4.5 mm cortex screws. The other end consists of an outer sleeve,
which has an end that corresponds exactly to the hemispherical
undersurface of the screw head, and an inner sleeve with diame-
ters 4.5 mm/3.2 mm used with the 3.2 mm drill bit. The two
sleeves are preloaded by a spring in such a way that the inner
sleeve protrudes at the tip. By applying pressure the inner
sleeve is pushed back into the outer sleeve. When the sleeve is
placed in the plate hole and pressure is applied, the rounded end
of the outer sleeve follows the inclined "cylinder" of the plate
hole to neutral position. The load position for a screw is ob-
tained by placing the protruding inner sleeve in the far end
(away from the fracture) of the plate hole. Similarly, the buttress
position is obtained when this sleeve is placed in the end of the
plate hole nearer the fracture.
Narrow LC-DCP, 4.5 mm in Pure Titanium

This plate has been specially designed for use on the tibia, but it
can be used sometimes on the radius or ulna in a large patient.
The plate can function as a neutralization, tension band or but-
tress plate, as desired. It is fixed with 4.5 mm titanium cortex
screws and, if located over cancellous bone, with 6.5 mm titani-
um cancellous bone screws.The 4.5 mm titanium shaft screws
are used as load screws for axial compression and as lag screws
for interfragmentary compression. The narrow 4.5 mm LC-
DCP is available with 2 to 16 holes.
- Thickness: 4.6mm
- Width: 13.5 mm
- Hole spacing: 18 mm
Broad LC-DCP, 4.5 mm in Pure Titanium

T his plate is designed for use on the femur and for pseud-
arthroses of the humerus. Any desired plate function can
be achieved with it. The broad LC-DCP, 4.5 mm is available
with 6 to 18 holes, which are staggered to prevent fissuring of
the bone.
- Thickness: 6.0mm
- Width: 17.5 mm
89 •
Semitubular Plates
As their name implies, semitubular plates are designed in the

shape of a half tube. They are only 1 mm thick and have low
rigidity. The plate should be used only in areas where they are
subject to tensile forces. Good rotational stability can be
achieved by means of the edges that dig into the bone. The oval
plate holes allow some axial compression if the 4.5 mm cortex
screws are inserted eccentrically on each side of the fracture.
A slight disadvantage of the plate hole is the deep penetration
of the unthreaded neck of the screw into the cortex, which en-
tails some risk of cortical splitting. Enlarging the cortex to
4.5 mm would prevent such splitting.
In the past the semitubular plate found its application in fore-
arm fractures.Today it may occasionally be used as a tension
band plate in open book injuries of the pelvis and as a second
plate in comminuted fractures in the metaphysis of long bones.
Sometimes it is used also for special orthopaedic procedures.
The semitubular plates can be used with the tension device.
Semitubular plates are available with 2 to 12 holes.
- Profile : see figure
- Thickness: 1mm
- Width: llmm
- Hole spacing: 16and26 mm
Reconstruction Plates, 4.5 mm
Reconstruction plates have been specially designed such that

they can be bent and twisted in two dimensions. They are there-
fore suitable in areas where exact and complex contouring is
necessary, e. g. the pelvis. The notches alongside the plate make
it possible to bend it into a curve on the flat, using special bend-
ing irons for reconstruction plates. It should be noted that the al-
ready low strength of the plate is further diminished by three-di-
mensional bending.Bending angles greater than 15 a at any one
site must be avoided.
~ The oval plate holes permit self-compression and accept both
...=
;. 4.5 mm cortex screws and 6.5 mm cancellous bone screws. The
plates are available with 3 to 16 holes.
-5
~ Important dimensions :
"C
; - Profile: see figure
...-;= - Thickness: 2.8mm
-e=
0
- Width: 12 mm
~
-=...=
...."'
• 90
6.5.1.2 Special Plates
The special plates are shaped to conform to specific anatomical

locations in the metaphysis and the epiphysis. In general they
are applied according to the same principles as the straight
plates, i.e. as compression plates, neutralization plates or but-
tress plates.
,..,
T Plates
T plates are designed to be used as buttress plates, especially on
the medial aspect of the tibial plateau. They are also applied in
proximal humerus fractures, for axial compression of a large
head fragment. The tension device is then used to exert com-
pression.
The head of the plate accommodates 6.5 mm cancellous bone
screws. The elongated hole is for loose temporary fixation with
a cortex screw. Longitudinal adjustment and tightening with the
tension device is then possible before fixation of the shaft. An-
gled lag screws can also be inserted through the elongated hole.
T plates are available with 3, 4, 5, 6 and 8 holes in the shaft and
68, 84, 100, 116 and 148 mm in length.
- Thickness: 2.0mm
- Width shaft: 17 mm
T and L Buttress Plates

T and L buttress plates are designed as buttress plates for the
lateral aspect of the tibial plateau. They differ from the ordinary
T plates only in their double bend, which contours to the lateral
side of the tibial plateau. The L buttress plates have an offset
head, one for the left and one for the right leg, to enable more
lateral buttressing without disturbing the fibula.
T buttress plates are available with 4, 5 and 6 holes in the shaft
and in lengths of 81, 96 and 112 mm, respectively The L buttress
plates have 4 holes only and are 81 mm long.
- Thickness: 2.0mm
."'=
-..
- Width shaft T buttress plate: 17 mm ~
- Width shaft L buttress plate: 16 mm

~
roo.
=
~
=..
0
~
Oil
..
~
....;!
.s
s::-
"'
~
~
91
•
6.5.2 Supplementary Plates
Lateral Tibial Head Buttress Plates

Lateral tibial head buttress plates are also designed as buttress
plates for fractures of the lateral tibial plateau with proximal
diaphyseal involvment. The plate has an expanded and shaped
upper portion or head. This is thinner than the shaft of the plate,
which has the same form as the narrow DCP, 4.5 mm. The shaft
is thicker than in the plates mentioned in 6.5.1.2 and is prefer-
able when proximal tibial fractures extend down into the dia-
physeal zone.
The DCP holes in the shaft accept 4.5 mm cortex screws; the
round holes in the slightly thinner head accommodate 6.5 mm
cancellous bone screws. The plate can be used with the tension
device.
..
Lateral tibial head buttress plates are available with 5, 7 and 9
holes in the shaft, for both the left and the right tibia.
Important dimensions :
- Shaft thickness: 3.8mm
- Width : 14 mm
Condylar Buttress Plates

Condylar buttress plates are used for the fixation of comminut-
ed fractures (C3) in the distal femur if a right angled condylar
plate cannot be used. The shaft is similar in size to that of the
broad DCP, and the DCP holes are staggered. The tension de-
vice can be hooked in the notch at the end of the plate. The head
portion with its round holes accepts the 6.5 mm cancellous bone
screws.
The plate is available with 7, 9, 11, 13 and 15 holes for both the
left and the right tibia.
- Shaft thickness: 5mm
- Width: 16mm
"'
Q,j
6- - Hole spacing: 16mm

·=-=
C.l
Cobra Head Plates
~
'C
Cobra head plates are used for arthrodesis of the hip. The head
=
--=
~
.s=
portion of the plate has round holes and is fixed with 4.5 mm
~
cortex screws. This plate also has a shaft similar to that of the
broad DCP with staggered DCP holes since it is applied to the
e
Q,j
...-=
femur. A notch at the end of the shaft accepts the tension device,
2 which is always used with this plate to exert enough axial com-
"' pression for the fusion .
• 92
For the technique of application, see the Manual ofInternal Fix-
ation (Muller et al.1979, pp. 388-389).
Long drill bits and taps are needed for the insertion of long
screws.
The cobra head plate is available with 8, 9, 10 and 11 holes in the
shaft.
- Shaft thickness: 6mm
- Width of shaft: 16mm
Narrow Lengthening Plates, 8Holes

Narrow lengthening plates are used in special lengthening pro-
cedures with the lengthening apparatus (see Sect. 6.13.4). The
plate has a middle section, without holes, in different lengths.
Depending on the achieved lengthening a corresponding plate
is chosen. The holes are of round hole design accepting 4.5 mm
cortex screws; 6.5 mm cancellous bone screws can be inserted in
the end holes, which also have notches for the tension device
used for distraction. The plate has 4 holes on each side and can
be used for lengthenings of 30, 40, 50, 60, 70 and 80 mm.
••
- Thickness: 3.6mm
-Width: 12 mm
Broad Lengthening Plates, 8 and 10 Holes

Broad lengthening plates are used for stabilisation of a length-
ened femur. The plates therefore have staggered holes, 4 on
each side, but their use is otherwise similar to that of the narrow
lengthening plate.They may be applied when lengthenings of
30, 40 ,50 and 60 mm have been achieved.
- Thickness: 4.5mm
-Width: 16 mm
Broad Lengthening Plates, 10 Holes

These broad lengthening plates have 5 holes on each side in-
stead of 4, but design and use are otherwise the same as that of
the previously mentioned plates. Lengthenings of 50, 60, 70, 80,
90, 100, 110 and 120 mm can be stabilised with these plates.
93 •
Spoon Plate
The spoon plate was designed as an anterior buttress plate for
distal tibial joint fractures (pilon) with anterior crushing but a
relatively intact posterior cortex. Experience has shown that it
is too massive an implant to be used on the subcutaneous anteri-
or crest of the tibia in acute fractures. Its indication today is re-
stricted mostly to metaphyseal nonunions of the tibia.
In the head portion 6.5 mm cancellous bone screws are used and
in the shaft 4.5 mm cortex screws. The small hole at the end is for
use with the tension device.
The spoon plate is available with 5 and 6 holes in the shaft and in
lengths of 100 and 120 mm.
- Thickness : 2.0mm
- Width of head : 33 mm
Cloverleaf Plate
The cloverleaf plate used to have a shaft that accepted 4.5 mm
cortex screws. This plate has been redesigned and is currently
used with small fragment screws only. For a further description
seep. Sect. 6.9.2.2.
6.5.3 Fixation Techniques with Large Plates
If a plate is used for the stabilisation of a fracture , it is applied ei-

ther as a compression plate, a neutralization or protection plate,
or as a buttress plate. See Sect. 4.3. The technique of application
differs and will be described for the most commonly used plates
in the following.
6.5.3.1 Applications of the DCP 4.5 mm
DCP, 4.5 mm, Applied as a Self-compression Plate
~ In transverse or short oblique fractures of the humerus the

6- broad DCP may be applied as a self-compressing tension band
] plate if lag screw fixation is not possible
(.I
~ Prerequisites:
"C
= - The plate must be placed on the tension side of the bone.
--=
~
= - Pre bending of the plate in the middle. See Sect. 6.5.6.

·=
~
Plate length: at least seven to eight cortices in each fragment
Q,j
(eight-hole plate).
--=
2
"'
=
• 94
- Reduction and temporary fixation of the fracture.
- The plate length is determined, and the plate contoured and
overbent at the centre.
- The first hole is drilled about 1 em from the fracture using the
3.2 mm drill bit in the 3.2 mm double drill sleeve end. This can
be done without the plate in place.
- The screw length is measured with the depth gauge through
( p the plate.
- The 4.5 mm tap in the 4.5 mm double drill sleeve end is used
r;r-.. _;; .;:r
1!.!0, """ to tap the cortex.
-
- A 4.5 mm cortex screw is inserted. To enhance the axial com-
pression the plate is pulled towards the fracture line, which
places the screw in load position.
- The reduction is checked and finalized and reduction forceps
applied.
- The yellow DCP drill guide, 4.5 mm, is placed in the load po-
sition (arrow toward fracture). The second hole is then drilled
( ) in the opposite fragment near the fracture.
- The hole is measured and tapped in a similar manner to the
t:r _;;;--/[' ;,;-~, /
y first.
(( - When tightening the 4.5 mm cortex screw axial interfragmen-
~ tary compression is exerted by means of the gliding spherical
-1-
principle.
- The first screw is now finally tightened.
- If enough compression has been obtained, the remaining
screws are inserted in the neutral position, alternating from
one side to the other.
- For this the holes are drilled with the 3.2 mm drill bit in the
green neutral DCP drill guide.
- The screw length is measured with the depth gauge.
- The 4.5 mm tap in the the 4.5 mm double drill sleeve end is
used to tap the bone.
- Insertion of the screw.
Note: At least the first six screws should be inserted one by one,
since the plate is displaced slightly with each screw tightening.
Multiple pre-drilled holes may otherwise be out of position.
If further compression is needed, a third screw may be inserted

@@@ (g@@ in load position:
- After inserting two screws in load position the yellow DCP
drill guide, 4.5 mm is placed in the next plate hole with the ar-
row directed toward the fracture.
- The 3.2 mm drill bit is used to prepare the hole.
95 •
- The hole is tapped with the 4.5 mm tap in the 4.5 mm double
drill sleeve end.
- Before tightening this screw, the previously inserted screw in
the same fragment is loosened.
- Final tightening of the second screw will achieve an addition-
al compression of 1 mm.
- Retighten the first screw.
A fourth screw can be inserted in load position in the opposite
fragment using the same procedure as described above. How-
ever, in such a case, it is better to use the articulated tension de-
vice.
Narrow DCP, 4.5 mm, Applied as Self-compression Plate.

Lag Screw Through the Plate
In oblique fractures one should enhance the axial compression
by placing a lag screw across the fracture. This can be done
either separately before the plate is applied or, when suitable,
through the plate.
Prerequisites:
- The plate must be placed on the tension side of the bone.
- Pre bending of the plate. See Sect. 6.5.6
Plate length: depends on the location. See Sect. 6.5.5
- The fracture is reduced, and the contoured and pre bent plate
fixed to the bone with reduction forceps.
- Using the double drill sleeve end, 3.2 mm, or the green, neu-
tral DCP drill guide, 4.5 mm, the first screw hole is drilled
with the 3.2 mm drill bit in the fragment, which forms an ob-
tuse angle with the undersurface of the plate.
to tap both cortices.
- The 4.5 mm cortex screw is inserted, but not fully tightened.
- In the opposite fragment the drill hole for the load screw is
prepared in the second plate hole, leaving the one nearest the
fracture vacant for the lag screw. The load (yellow) DCP drill
guide, 4.5 mm, is placed in the hole with the arrow pointing
'I.
toward the fracture and the hole drilled using the 3.2 mm drill
Ql
bit.
=
·~ - The hole is measured and tapped with the 4.5 mm tap in the
'€ corresponding size sleeve.
~ - Insertion of the screw will exert axial compression between
'C
; fragments. The screw is tightened firmly.
--=
·==~
- The first screw is tightened firmly as well. If further axial com-
pression is necessary, a second load screw can be inserted in
the plate hole next to the already inserted load screw.
e - A gliding hole for the lag screw is now prepared. The 4.5 mm
Ql
- 2
".....'
=
drill bit in the 4.5 mm double drill sleeve end is used to drill
the hole in the near cortex in the desired direction of the
screw.
• 96
- The 3.2 mm double drill sleeve end is pushed through the
gliding hole across the medullary cavity until it abuts the far
cortex.
- Using the 3.2 mm drill bit the thread hole is drilled in the far
fragment.
- Tapping of the thread hole is performed using the 4.5 mm tap
in the 4.5 mm double drill sleeve end.
- The 4.5 mm cortex screw is inserted and tightened. Interfrag-
mentary compression across the fracture is enhanced.
- The remaining screws are inserted in neutral position using
the green, neutral DCP drill guide, 4.5 mm, alternating from
one side to the other: drill bit 3.2 mm, tap 4.5 mm, depth
gauge, and screw.
@)@)@)
Note: Once a lag screw has been placed across the fracture, no
further load screw can be inserted. The interfragmentary com-
pression would otherwise be compromised.
Narrow DCP, 4.5 mm, as a Neutralisation or Protection Plate
In spiral or wedge fractures of the diaphysis, lag screw fixation

may be used to achieve interfragmentary compression. Lag
screw fixation alone cannot withstand functional load, there-
fore a plate should be applied to protect (or neutralise) the pri-
mary lag screw fixation against torsional and shearing forces.
Note: Any screw introduced through the plate that crosses the
fracture should be inserted as a lag screw.
Prerequisites:
- Separate lag screw fixation first.
- Exact contouring of the plate.See Sect. 6.5.6.
Plate length: depends on the site of fracture and its configura-
tion. Two to four screws in the main fragments.
."'=
-.=
~
Col
r.o.
~
=
=..
0
~
~
...s=
,_;j
-=
"'
~
==
97
•
- Reduction of the fracture. A template is used to determine
the contour of the plate (Fig.l).
- Insertion of the lag screws for fixation of the fracture by inter-
fragmentary compression.
- The contoured plate is fixed to the bone using reduction for-
ceps.
- Through a plate hole near the fracture the 3.2 mm drill bit in
the green, neutral DCP drill guide, 4.5 mm, is used to drill the
hole for the first screw (Fig. 2).
- The screw length is measured (Fig. 3).
to tap both cortices (Fig. 4).
- The 4.5 mm cortex screw is inserted (Fig. 5).
- On the opposite side the second screw hole is prepared also us-
ing the green, neutral DCP drill guide and the 3.2 mm drill bit
(Fig. 6), followed by measuring, tapping and insertion of the
screw (Fig. 7).
- Whenever possible a 4.5 mm cortex screw is inserted as a lag
screw across the fracture.
- Using the neutral DCP drill guide 4.5 mm and the drill bit
3.2 mm the thread hole is drilled through both cortices
(Fig.8).
- The depth gauge is used to determine the length (Fig. 9).
- The hole is tapped with the 4.5 mm tap in the double drill
sleeve end, 4.5 mm (Fig.lO).
- The near cortex is overdrilled with the 4.5 mm drill bit in the
double drill sleeve end, 4.5 mm (Fig.ll ).
- The 4.5 mm cortex screw is inserted (Fig. 12). Interfragmen-
tary compression is achieved.
- All the remaining screws are inserted alternating from one
side to the other using the same instruments and the same
step by step technique as mentioned above. A short screw is
inserted if a lag screw has to be avoided (Fig.13).
<ll
=
~
=-
·=
-=
<:..1
~
-=;
=
Q
;:
....
~
=~
-...a=
""'<ll 5
• 98
~·
..
-..
"'
~
=
IJ
~
""=
~
=..
0
~
!:)!)
..
~
....;l
.s
9 13 -"'
~
~
6:
99
•
Narrow or Broad DCP, 4.5 mm, Applied as a
Compression Plate with the Articulated Tension Device
As a general rule, the tension device is used with the DCP if the
bone has to be transposed farther than 2 mm (pseudarthroses)
or if compression more than 80 kp is required (e. g. for the fe-
mur).
Whenever possible, a lag screw should be inserted through the
plate, across the fracture.
Prerequisites:
- Pre bending of the plate. See Sect. 6.5.6.
- Enough space to attach the tension device.
Plate length:
- Tibia: At least six to seven cortices in each fragment (seven-
hole plate)
- Femur: At least seven to eight cortices in each fragment
(eight- hole plate).
- The first screw hole is drilled 1 em from the fracture using the
3.2 mm drill bit in the 3.2 mm double drill sleeve end.
- The screw length is measured with the depth gauge through
the plate.
- Tapping is done with the 4.5 mm tap in the 4.5 mm double
drill sleeve end.
- The fracture is reduced and the contoured, overbent plate is
loosely attached to the bone with the first screw. The plate is
pulled toward the fracture, placing the screw in an eccentric
load position. One or two further screws are inserted.
- The articulated tension device is opened and hooked into the
last plate hole on the opposite side. The screw hole is pre-
pared through the foot plate with the 3.2 mm drill bit in the
3.2 mm double drill sleeve end.
- The drill hole is tapped.
- The tension device is usually fixed to the bone with a 16 mm
cortex screw.
- To stabilise the fracture the tension device is gently tightened
with the combination wrench. During this procedure the re-
rll
= duction is checked.
~
.S' - All the screws are inserted in sequence in the first fragment:
=
of 3.2 mm drill bit in the neutral, green 4.5mm DCP drill guide,
~
Fo depth gauge, 4.5 mm tap in 4.5 mm double drill sleeve end, in-
] sertion of the screws.
eo:
c - The articulated tension device is now tightened with the com-
.~
-; bination wrench to achieve axial compression.The coloured
C rings indicate the amount of pressure excerted at the fracture
e site. Seep. 67.
~
=
.!: - Whenever possible a 4.5 mm cortex screw is inserted as a lag
=
'I;
.... screw across the fracture .
• 100
- All the screws are inserted in the second fragment in the man-
ner as described above.
- The articulated tension device is removed, and its over-
stressed anchoring screw is discarded.
- The last screw hole is drilled, measured, and tapped, and the
last 4.5 mm cortex screw inserted.
Note: The tension device should be applied to the fragment,
which produces an acute angle under the plate. Placed on the
wrong side it will cause displacement at the fracture interface
when tightened.
DCP, 4.5 mm, as a Buttress Plate
A buttress plate is applied to prevent a fractured zone from col-

lapsing. All screws are placed in buttress position, i.e. in the por-
tion of the plate holes nearest the fracture, since no compression
is desired.
If one end of the plate is fixed to the metaphysis using 6.5 mm
cancellous bone screws, then these screws must be inserted first.
Prerequisites:
- Exact contouring of the plate. See Sect. 6.5.6.
- All screws in buttress position.
Plate length: depends on the localization of the fracture.
Step by step procedure :
- The fracture is reduced and the exactly contoured plate fixed
to the bone with reduction forceps.
- The first plate screw is inserted in a plate hole near the frac-
ture. The 3.2 mm double drill sleeve end is placed in buttress
position in the plate hole and a thread hole drilled with the
3.2 mm drill bit.
- The length is measured.
- The thread hole is tapped with 4.5 mm tap in the 4.5 mm dou-
ble drill sleeve for a cortex screw or with 6.5 mm tap and
6.5 mm double drill sleeve for a cancellous bone screw.
- A screw of appropriate length is inserted.
- The second screw is inserted in the opposite fragment near
the fracture: drill bit 3.2 mm in the 3.2 mm double drill sleeve
end in buttress position.
- The thread hole is tapped with 4.5 mm tap in 4.5 mm double
drill sleeve end.
- The screw is inserted.
- The remaining screws are inserted in a similar manner, alter-
nating from one side to the other: drilling, measuring, tapping
and inserting the screw.
Note: Any cortex or cancellous bone screw that crosses the frac-
ture must be inserted as a lag screw. The screw thread must grip
only the far fragment.
101
•
6.5.3.2 Applications of the LC-DCP, 4.5 mm
LC-DCP, 4.5 mm Applied as a Self-compression Plate.

Lag Screw Through the Plate
In a short oblique fracture the plate can be applied to achieve

both axial and interfragmentary compression. This is achieved
by inserting a load screw and a lag screw through the plate. The
uniform hole spacing and the evenly distributed stiffness along
the plate makes the positioning of the plate easy. Titanium
screws are used in titanium plates.
Prerequisites:
- Application on the tension side of the bone.
- Prebending of the plate. See Sect. 6.5.6.
Plate length:
- Each main fragment must carry screws anchored within at
least six cortices.
- Plate holes can be left free , if necessary, or occupied with a
short screw.
- The fracture is reduced and the prebent plate fixed to the
bone with reduction forceps. One plate hole in the middle is
left vacant for the lag screw.
- The first screw is inserted near the fracture in the fragment,
which forms an obtuse angle with the undersurface of the
plate. The neutral (green) LC-DCP drill guide, 4.5 mm, is
placed in the plate hole with its arrow toward the fracture. The
thread hole is drilled with the 3.2 mm drill bit in both cortices.
screws in the 4.5 mm end of the double drill sleeve.
- A 4.5 mm titanium cortex screw is inserted with the large
hexagonal screwdriver, but not completely tightened.
- The plate hole nearest the fracture in the opposite fragment is
left vacant for the lag screw. In the next hole the LC-DCP load
(yellow) drill guide, 4.5 mm, is placed with the the arrow to-
ward the fracture and the thread hole drilled with the 3.2 mm
~ drill bit in both cortices.
S. - After measuring the length, the thread hole is tapped with the
] tap for 4.5 mm cortex screws in the double drill sleeve end,
~ 4.5 mm.
"= - The near cortex is overdrilled with the 4.5 mm drill bit in the
; double drill sleeve end, 4.5 mm, since a shaft screw is required
--e=
.=
: to apply load .
~
- A 4.5 mm titanium shaft screw is inserted and finally tight-
~ ened, but only after the first screw has been driven home.
-
2 Axial compression is then achieved.
';;
=
• 102
- A second and even a third load screw can be inserted if fur-
ther compression is necessary. This screw should not be tight-
ened whitout first loosening the first load screw.
- The thread hole for the lag screw is now prepared in the va-
cant plate hole using the LC-DCP universal drill guide,
4.5 mm. The guide is pressed into the plate hole in the desired
direction. This ensures congruent fit between screw head and
plate hole. Both cortices are drilled with the 3.2 mm drill bit.
A three-fluted drill bit positions the drill hole more accurate-
ly than a two-fluted drill bit.
- After measuring, the hole is tapped with the tap for 4.5 mm
cortex screws in the 4.5 mm end of the LC-DCP universal
drill guide, 4.5 mm.
- The near cortex is then overdrilled with the 4.5 mm drill bit in
the 4.5 mm end of the universal drill guide, maintaining the
original direction.
- The 4.5 mm titanium shaft screw is inserted. Interfragmen-
tary compression is thus achieved.
- The remaining screws are inserted using the neutral, green
LC-DCP drill guide, 4.5 mm. The arrow points toward the
fracture.
- Final tightening of all screws.
Variation 1: The LC-DCP universal drill guide,4.5 mm, can be
used instead of the LC-DCP drill guide, 4.5 mm, to drill for all
screws. The neutral position for screws is obtained by pressing
the guide into the plate hole ; the load position, by positioning
the protruding tip eccentrically, in the end of the plate hole far
from the fracture.
Variation 2: The articulated tension device is used with the LC-
DCP whenever greater compression is required, i.e. in femur
fractures, in porotic bone, or in metaphyseal applications. The
LC-DCP is fixed with at least three screws in the fragment,
which forms an obtuse angle with the plate undersurface. Then,
after careful reduction, the opened articulated tension device is
mounted in the opposite plate end and fixed to the bone with a
4.5 mm cotrex screw. Axial compression is achieved by carefully
tightening the bolt of the device. Before removing the articulat-
ed tension device, the plate is fixed with 4.5 mm titanium cortex
screws to this fragment. The screw used to attach the articulated
tension device should not be used later as a plate fixation screw.
LC-DCP, 4.5mm Applied as a Neutralisation

or Protection Plate
In spiral fractures or fractures with a wedge fragment, i.e. the

lower tibia, a LC-DCP, 4.5 mm may be used instead of a DCP,
4.5 mm. Prebending of the plate and positioning is easier with
the LC-DCP, because of its uniform hole spacing and the evenly
distributed stiffness along the plate.
103
•
Titanium screws are used with titanium plates.
Prerequisites:
- Lag screw fixation separately, and if possible through the
plate.
- Exact contouring of the plate. See Sect. 6.5.6.
Plate length: depends on fracture site and configuration. Two to
four screws in each main fragment.
- Reduction of the fracture and lag screw fixation with either
4.5 mm or 3.5 mm cortex screws (Fig.l ).
- Using a template as model, the plate is carefully contoured
and provisionally fixed to the bone with reduction forceps.
- The first plate screw is inserted in one of the main fragments
without crossing the fracture. The drill bit, 3.2 mm, in the LC-
DCP drill guide, 4.5 mm, is used to drill the thread hole
(Fig.2).
- The screw length is measured using the depth gauge (Fig. 3).
screws in the 4.5 mm end of the double drill guide (Fig. 4).
- The 4.5 mm titanium cortex screw is inserted with the large
hexagonal screwdriver (Fig. 5).
- If any of the subsequent screws are crossing the fracture, they
should be inserted as lag screws: The LC-DCP universal drill
guide,4.5 mm, is pressed into the plate hole in the desired di-
rection and the thread hole drilled with the 3.2 mm drill bit in
both cortices (Fig. 6).
- The length is measured (Fig. 7).
- The tap for 4.5 mm cortex screws in the 4.5 mm end of the uni-
versal drill guide is used to tap both fragments (Fig. 8).
- Without changing direction the near cortex is overdrilled
with the 4.5 mm drill bit in the 4.5 mm end of the LC-DCP
universal drill guide (Fig. 9).
- The chosen 4.5 mm titanium shaft screw is inserted with the
large hexagonal screwdriver (Fig.lO).
- Interfragmentary compression has been achieved.
- The remaining screws, not crossing the fracture , can be insert-
ed as regular plate screws using the neutral LC-DCP drill
~ guide, 4.5 mm (Fig.ll ).
;. - Final tightening of all screws (Fig.l2).
·=.c
~ Note: Not all plate holes need to be occupied by screws. A short
~ screw can be inserted if the fracture location so requires.
"C
;
--
c
·=
~
c~
e
-2
...."'
c
• 104
5
10
12
105 •
LC-DCP, 4.5 mm, Applied as a Buttress Plate
Like the DCP, the LC-DCP can be used as a buttress or as a

bridging plate to prevent fracture zone collapse. All screws
should be inserted in the buttress position to avoid compres-
sion.
Prerequisites:
- Careful contouring of the plate. See Sect. 6.5.6.
- All screws in buttress position.
Plate length: depends on the localization of the fracture.
- The fracture is reduced and the contoured plate fixed to the
bone with reduction forceps.
- The first screw is inserted near the fracture using the green
neutral LC-DCP drill guide with the arrow pointing away
from the fracture. The thread hole is drilled with the 3.2 mm
drill bit.
- The screw length is measured and the hole tapped with the
tap for 4.5 mm cortex screws and the double drill sleeve,
4.5mm.
- The 4.5 mm titanium cortex screw is inserted with the large
hexagonal screwdriver and tightened firmly.
- The procedure is repeated in the opposite fragment. Using
the neutral LC-DCP drill guide with the arrow pointing away
from the fracture, the thread hole is drilled, measured, and
tapped, and the 4.5 mm titanium cortex screw inserted.
- If required, a lag screw can be inserted through the plate. De-
pending on the location it may be a cortex or a cancellous
bone screw.
- The remaining screws are inserted in the buttress position us-
ing the technique described for the first screw.
6.5.3.3 Application of Semitubular Plates
Semitubular Plate as a Tension Band Plate

"'
g.
~
The semitubular plate can be used for the fixation of transverse
~ fractures in, for example, the forearm, where the plate would be
~ subject to tension only. The oval holes allow insertion of screws
~ in a slightly eccentric position. If the fracture is perfectly re-
= duced, axial compression can be exerted through this self-com-
-=
.5!=
..!
pressing effect.
If a cancellous bone screw is used in this plate it is inserted first. lo o ~ @ o o!1
e
~
-=
2
"'
....
• 106
- Reduction and careful contouring and overbending of the
plate.
- In the plate hole nearest the fracture on one side a hole is
drilled with the 3.2 mm drill bit in the 3.2 mm end ofthe double
2
drill sleeve, in an eccentric position, away from the fracture.
- The hole is tapped with the 4.5 mm tap in the 4.5 mm end of
the double drill sleeve.
- The 4.5 mm cortex screw is inserted until the screw head
abuts the plate.
3 [0 0@ @ 0 0 [ - After pulling the plate toward the opposite fragment, the sec-
ond screw hole is drilled through the plate hole nearest the
fracture in this fragment. This is also in eccentric position.
The reduction must be maintained (Fig.1 ).
- Tapping for 4.5 mm cortex screw.
- Insertion of the second cortex screw (Fig. 2).
- Final tightening of the first screw. A certain amount of axial
4 compression is achieved (Fig. 3).
- Insertion of the remaining screws, alternating from one
side to the other: drilling 3.2 mm, measuring and tapping
4.5 mm (Fig.4).
Note: The articulated tension device can also be used with the
semitubular plates. It is used as described for DCP, 4.5 mm
(Fig.5).
6.5.3.4 Application of 4.5 mm Reconstruction Plates
4.5 mm Reconstruction Plate as a Self-compressing Plate
The 4.5 mm reconstruction plate is mainly used for the fixation

of pelvic fractures in large individuals.
By means of the oval shaped holes, axial compression can be ex-
erted by inserting the screws eccentrically on each side of the
fracture. Depending on the bone quality, 4.5 mm cortex screws
or fully threaded 6.5 mm cancellous bone screws are used.
The plate should be contoured carefully by using the special
bending irons. The plate holes may otherwise be distorted and
cannot accept the screws. Bending angles greater than 15 o at
any one site must be avoided. See Sect. 6.10.1.
- The fracture is reduced and the plate carefully contoured and
applied to the bone with reduction forceps.
- The first screw hole is drilled in the plate hole nearest the frac-
ture with the 3.2 mm drill bit in the 3.2 mm end of the double
drill sleeve.
107
•
- Measuring the length.
- Tapping with the 4.5 mm tap for the cortex screw, 4.5 mm. For
a cancellous bone screw tapping may not be necessary.
- Insertion of the selected screw.
- The second screw hole is prepared in the same fashion on
the other side of the fracture but placing the drill hole eccen-
trically.
- Measuring.
- Tapping.
- Tightening the screw will exert some axial compression at the
fracture interface.
- The remaining screws are inserted alternating from side to
side.
6.5.3.5 Application ofT Plates and L Plates
Application ofT or L Plates as Buttress Plates
T and L buttress plates are designed to fit the medial and lateral
aspects of the proximal tibia. Even though they are shaped to fit
the bone they may still need exact contouring before applica- = ·
tion. =
- Reduction of the fracture and careful contouring of the plate.
- Temporary fixation of the plate through the ovally shaped
hole: drill bit 3.2 mm in the 3.2 mm end of the double drill
sleeve, measuring and tapping for the 4.5 mm cortex screw.
The screw is loosely inserted.
- After adjusting the plate to its final position, the 3.2 mm drill
bit in the 3.2 mm end of the double drill sleeve is used to drill
the next hole.
- Tapping with the 4.5 mm tap in the 4.5 mm end of the double
drill sleeve.
- Inserting the 4.5 mm cortex screw.
- The remaining screws are inserted using the same step by step
technique.
- The screw inserted through the oval hole is tightened a last
"'
·a -
~ time.
In the tibial head the drill bit 3.2 mm in the 3.2 mm double
-s drill sleeve end is used to prepare the holes for the 6.5 mm
~ cancellous bone screws. If this screw is crossing the fracture
] and there is no comminution, it should be inserted as a lag
~
=
Q
screw. The thread must grip the far fragment only. The correct
thread length must be chosen. Depending on the fracture
~
=
§..
~
these screws may be the first inserted.
-
- Measuring of the length .
- Tapping the near cortex only using the 6.5 mm tap in 6.5 mm
..."=' double drill sleeve end .
• 108
- Insertion of the 6.5 mm cancellous bone screw.
- The second hole in the tibial head is fixed with a cancellous
bone screw in similar manner.
Note: These plates are sometimes used in the proximal
humerus, where they may be used with the articulated tension
device to achieve interfragmentary compression.
6.5.3.6 Application of the Lateral Tibial Head Buttress Plate
The lateral tibial head buttress plate is an alternative to the Lor

T buttress plate for fixation of tibial plateau fractures and is ap-
plied to the lateral aspect of the upper tibia. The DCP section of
the plate is stronger than the T and L buttress plates and is
therefore used when the fracture complex extends distally to in-
volve the upper diaphyseal region. Its use is similar to the proce-
dure described above forT and L buttress plates, except that it
does not have the oval positioning hole, and its placement must
be verified accurately before the first plate fixation screw hole is
drilled.
6.5.3.7 Application of the Condylar Buttress Plate

l. =
The condylar buttress plate is in general used in complex distal
l fractures by very experienced surgeons. No standard, step by
(
step procedure can be described. The surgeon will customise
l the operative tactics to each individual fracture problem ac-
l cording to a carefully prepared preoperative plan.
(.,
t
tJ
c, ,
{ v
y
6.5.4 Plate Length and Engaged Cortices
A certain number of screws is necessary to prevent mechanical

failure of a plate fixation.This varies from bone to bone, and de-
pends to some degree on the size and weight of the individual. In
all types of plate fixation, however, the law of proportionality
must be observed. A roughly equal number of cortices should
be securely engaged in both main fragments. Only the number
of screws necessary should be used, since every screw compro-
mises bone vitality, and not every hole in a plate must be filled.
Screws should not be placed in a fracture line or into a very small
fragment. The latter may result in devitalisation of the frag-
ment, delay in callus formation, and consequent failure.
109
•
As a general rule the following number of cortices should be en-
gaged in the various bones :
- Forearm: five to six cortices at least six-hole plate
-Humerus seven to eight cortices at least eight-hole plate
- Tibia six to seven cortices at least seven-hole plate
-Femur seven to eight cortices at least eight hole plate
- Clavicle five to six cortices at least six-hole plate
Shorter plates are an exception. Longer plates may be necessary
to securely engage enough cortices.
6.5.5 Contouring of Plates
Before a straight plate is applied it must be contoured to fit the

bone exactly. Adverse forces may otherwise occur when tight-
ening the screws, resulting in loss of reduction and possible loos-
ening. Overbending (prestressing) the plate is necessary when
the plate is loaded, otherwise as it compresses the fracture,
some opening of the fracture plane may occur in the cortex op-
posite the plate. See Sect. 4.3.
The special plates, as well as angled blade plates, may also have
to be contoured. The plates are bent either with the bending
press or the bending pliers and twisted about their long axis with
twisting irons.
The aluminium bending templates of corresponding size are
first moulded to the bone and then used as a model when con-
touring the plate.
Bending back and forth weakens the plate and should be avoid-
ed.
The plate should be bent between the holes. It must be properly
placed in the bending instruments to avoid sharp indentations.
• 110
Bending Press
- The handle is placed in the neutral position and the jaws ad-
justed to the plate thickness.
- The plate is placed at the front for concave bending; for con-
vex bending it is placed at the back. The knurled knob is
turned until the plate is held firmly between the anvil and the
upper jaw.
- The plate is bent between holes in small increments without
the need for great force until the desired shape is reached.
- While holding the plate in the press, it can be twisted with a
bending (twisting) iron. The bend of the plate must be
checked after the twisting. Further contouring may be neces-
sary.
Bending Pliers
- The pliers are adjusted to the plate thickness and to the grip of
the surgeon by turning the knob at the end of the handle.
- The plate is bent between the holes and in small increments.
- By placing the plate obliquely in the jaws, the plate can be
twisted.
..="'
-..
~
~
~
=
~
=
Q
.
~
~
..
~
...;!
.s
-"'
~
~
5::
111
•
6.5.6 AO/ASIF Instruments for Application
of Large Plates
Instruments for the application of DCP,

4.5 mm, condylar buttress plates, and lat-
eral tibial head buttress plates
Instruments for the application of LC-

DCP,4.5mm
I'
I Instruments for the application of T

l
II
plates, T and L buttress plates, semitubu-
lar plates, spoon plates and reconstruction
plates, 4.5 mm
/
• 112
6.6 The Cannulated Screw System
Often, when a fracture in the metaphysis or the epiphysis has

been reduced and temporarily fixed with a Kirschner wire, the
site of the wire is found to be ideal for the screw. Cannulated
screws in three different sizes have been introduced to enable
insertion over guide wires.
The 7.0 mm cannulated screw is used for metaphyseal/epiphy-
seal fractures of large bones, such as femur, proximal tibia, and
all of the pelvis. The 4.5 mm cannulated screw finds its applica-
tion in medium sized bone, i.e. distal humerus, patella, distal
tibia, calcaneus etc. The 3.5 mm cannulated screw is used for the
fixation of small fragments in the wrist, the hand and the foot.
Cannulated screws are currently available only in stainless steel.
Due to the cannulation, neither the instruments nor the im-
plants are as strong as their noncannulated counterparts and
should therefore be used with care.
The coloration process of some of the guide wires is similar to
that used for anodised titanium implants. The wires are im-
mersed in a specially formulated electrochemical solution that
increases the thickness of the protective surface oxide. The
specific colour that is produced depends upon the oxide film
thickness that is controlled in the anodising process. Visible
light diffraction within the oxide film creates a distinct co-
lour. No colouring agents or additives are present in the surface
film and animal studies have shown no increased tissue inflam-
mation in comparison with unanodised stainless steel speci-
mens.
6.6.1 The 7.0 mm Cannulated Screw System
The primary indications for 7.0 mm cannulated screws are frac-

tures involving large metaphyseal/epiphyseal fragments such
as:
- Intracapsular fractures of the hip
- Tibial plateau fractures
- Femoral intercondylar fractures
- Paediatric femoral neck fractures
- Slipped capital femoral epiphysis
- Ankle arthrodesis
- Sacroiliac joint disruptions
The screws are applied as lag screws and can be inserted percu-
taneously, or through a normal surgical approach.
The 7.0 mm cannulated screws in different lengths and the in-
struments for their application can be obtained in either a
graphic case or in a sterilising tray.
113
•
Note: In the US some of the large plates have modified plate
holes to accommodate the 7.0 mm cannulated screw. See the
SYNTHES USA catalogue.
6.6.1.1 Instruments
Threaded Guide Wire, 2.0 mm Diameter, 230 mm
The guide wire has a threaded spade point tip to facilitate inser-
tion. It is inserted after reduction at the site where the screw is to
be placed. The use of a drill sleeve prevents creeping of the wire
on the bone surface. The 8 mm long threaded tip should be well
anchored in the subchondral bone to ensure correct measure-
ment of the screw length with the measuring device. The correct
position is confirmed with an image intensifier.
For easy identification some of the wires are coloured blue. The
guide wire must be checked for damage and bends before inser-
tion, or else it will bind and be pushed forward with the drill bit,
causing damage.
Drill Bit, 2.0 mm Diameter
The drill bit, 100 mm/75 mm, is used to pre-drill a dense cortex
before insertion of the threaded guide wire or a Kirschner wire
used for reduction.
'E if7Sii?"'t :zaza '-==:1

Cannulated Drill Bit, 4.5 mm Diameter, Three-Fluted
The 4.5 mm, three-fluted cannulated drill bit, 230 mm/210 mm,
has a cannulation of2.1 mm to fit over the threaded guide wire,
2.0 mm. The three cutting edges facilitate cutting at angles and
prevent skidding. It is calibrated to allow direct reading of the
drilled depth, except when drilling through the percutaneous
sleeve assembly. The drill bit has a triangular end which fits into
a Jacobs chuck. Because of the cannulation the drill bit is weak-
er than a solid one. Bending or excessive axial force must be
"' avoided during drilling to prevent breakage.lt should always be
~
·a
=" used with a drill sleeve of the same diameter.
.c:
1.1
~
-=
= Percutaneus Sleeve Assembly
--=
~
=
·=
~
- The protection sleeve, 11.0 mm/8.0 mm, 88 mm long, with
handle is used as the outermost component in the percuta-
e
Q,l
-......==
neous sleeve assembly. All steps can be performed through
this sleeve, including measuring, tapping and inserting
"' screws .
• 114
- The drill sleeve, 8.0 mm/4.5 mm in diameter, 99 mm long, is
used within the sleeve mentioned above while drilling.
- The drill sleeve, 4.5 mm/2.0 mm in diameter, 108 mm long, is
used inside the two instruments just described to reduce the
risk of deflection when inserting the threaded guide wire,
2.0mm.
- The trocar, 2.0 mm in diameter, 118 mm long, is the inner-
most part of the percutaneous sleeve assembly and is used to
facilitate passage of the assembly through soft tissue down to
the bone.
Parallel Drill Guide, 4.5 mm Diameter
With the drill guide additional, parallel threaded guide wires

can be placed for parallel screws in percutaneous or open proce-
dures.These may be inserted at distances of 10, 14, or 18 mm. If
washers are to be used with the screws the 14 or 18 mm marked
holes should be used to allow enough space for the washers.
Parallel Wire Guide, 2.0 mm Diameter
With the wire guide, it is possible to place threaded guide wires

in parallel at 130 o in open fixation of femoral neck fractures so
that multiple screws can be placed accurately. The centre holes
are used for preliminary fixation and the threaded guide wires
for the cannulated screws are inserted through the outer holes.
The head has spikes to help secure the instrument on the bone
surface during use.
The drill sleeve is used with the cannulated drill bit.
Cannulated Screw Measuring Device, 7.0 mm
The cannulated screw measuring device is used to determine the

screw length by sliding it over the guide wire. The length mea-
sured is 8 mm shorter (length of the threaded tip) than the over-
alllength of the guide wire within the bone. The screw is thus
prevented from penetrating the far cortex, and the threaded
portion of the guide wire remains anchored during drilling, tap-
ping, and screw insertion, provided the measured depth is not
exceeded. The pencil-like measuring device formerly used has
been replaced by this device, which can be used also in percuta-
neous procedures through the protection sleeve, 11 mm/8 mm.
Some devices are made of anodised aluminium and coloured
115
•
blue. Care must be taken when cleaning these devices. See
Sect. 6.22.4.2
Cannulated Tap for the 7.0 mm Cannulated Screw
The cannulated tap is used to cut the thread in the near cortex
(or the entire length of the non threaded part of the guide wire in
dense bone) prior to insertion of the screw. The calibration
helps confirm the tapping depth. The percutaneous protection
sleeve, 11 mm/8 mm, or the tap sleeve for the 6.5 mm cancellous
bone tap can be used for soft tissue protection.
Note: The calibration is designed to be read at the bone surface
and not at the outer end of the drill sleeve.
Large Cannulated Hexagonal Screwdriver
The large cannulated hexagonal screwdriver, 3.5 mm in width

across flats, is used to insert the 7.0 mm cannulated screws over
the guide wire. Because of its cannulation, excessive force
should not be applied with this screwdriver since it is not as
strong as a solid one. The ordinary, large hexagonal screwdriver
should be used for final tightening and to remove the screws.
The screwdriver is fully cannulated and the shaft has a groove to
accept the large holding sleeve.
Large Holding Sleeve
The large holding sleeve is a self-retaining screw-holding sleeve,

which can be used with those large hexagonal screwdrivers
equipped with a grooved shaft. The holding sleeve grips the
screw head during insertion in areas with reduced visibiliy, or
when removing screws with a smooth shaft, allowing traction to
be applied. The sleeve must be carefully disassembled for clean-
ing. See also Sect. 6.22.4.
"'~ Cleaning Stylet, 2.0 mm Diameter

](,I The stylet is used for cleaning all cannulated instruments, also
~ intraoperatively to prevent accumulation of debris and there-
-=§ fore binding of the instruments around the guide wire.
=
0
i
=e Screw Forceps
Q,l
-..= The screw forceps is self-retaining and used to remove screws

.s"' from the screw rack.
• 116
6.6.1.2 Supplementary Instruments
Cleaning Brush, 2.1 mm
The brush is made of autoclavable nylon on a steel shaft. It is

used to clean 2.1 mm cannulated instruments.
6.6.1.3 Implants
The 7.0 mm Cannulated Screw
- Screw head diameter: 8.0 mm
r
4,5 @ 3,5 - Screw head height : 4.5 mm
I - Hexagonal socket width: 3.5 mm
~ - Shaft diameter: 4.5 mm
4.5 @ - Core diameter: 4.5 mm
~~ -l l..
2.1 - Pitch : 2.75mm
7.0 2.75 4,5
s~ - Cannulation: 2.1 mm
The screws are available with a 16 mm long thread in lengths of
30 mm- 130 mm and with a 32 mm long thread in 45 mm-
130 mm in 5 mm increments. Fully threaded screws are also
available as supplementary implants if desired. The screw also
has reverse-cutting flutes for easy removal.
Washer, 13 mm
The washer is used with the screw to prevent the screw head
from sinking into the thin cortex in the metaphysis or the epiph-
ysis. The flat surface is placed onto the bone; the countersink re-
ceives the screwhead.
6.6.1.4 Technique oflnsertion o£7.0 mm Cannulated Screws
In, for example, a femoral neck fracture three screws are usually
inserted. Image intensification is strongly recommended.
Percutaneous Insertion of Screws, Closed Procedure
- T he fracture is reduced, and a regular, 230 mm long Kirschner

wire or threaded guide wire is inserted along the anterior as-
pect of the femoral neck to determine the anteversion. The
telescoping wire guide may be used. Image intensification is
used for confirming correct placement.
- Through a stab incision and by blunt dissection the percuta-
neous sleeve assembly is pushed onto the lateral cortex and
positioned parallel to the anteversion wire in the coronal
plane (Fig.1 ).
117
•
- The 2.0 mm trocar is removed and the 2.0 mm threaded guide
wire inserted to the appropriate depth. To prevent slippage
the 4.5 mm/2.0 mm sleeve may be tapped with a hammer to
seat its teeth in the bone. The drill should be run at maximum
speed to minimise deflection while gradually advancing the
wire (Fig. 2). The correct position in antero-posterior (AP)
and lateral views is verified with the image intensifier.
- Proper screw length is determined with the cannulated screw
measuring device, used through the 11.0 mm/8.0 mm protec-
tion sleeve (Fig. 3). The length measured is 8 mm short of the
threaded portion of the wire to prevent penetration of the far
cortex (see alsop. 115).
- The 8.0 mm/4.5 mm drill sleeve is reinserted and the cannu-
lated drill bit, 4.5 mm, used to drill over the threaded guide
wire under image intensifier control. Depending upon the
bone quality, only the near cortex may be drilled. In dense
bone the entire unthreaded length of the guide wire is drilled
(Fig. 4). The drill is removed slowly and pulled back straight,
taking care not to pull out the wire. The drill should not be run
in reverse as this risks unthreading the guide wire, should
there be any binding between wire and drill.
- The 8.0 mm/4.5 mm sleeve is removed and the near cortex
tapped through the 11.0 mm/8.0 mm protection sleeve. In
dense bone virtually the entire length over the unthreaded
part of the guide wire is tapped (Fig. 5).
- The large cannulated hexagonal screwdriver, without holding
sleeve, is used to insert the selected screw through the
11.0 mm/8.0 mm sleeve. If a washer is used, the protection
sleeve has to be removed to place the washer over the guide
wire (Fig. 6).
- A second and a third screw may be inserted using the same
technique as described for the first screw. Another possibility
is to use the parallel drill guide.
rll
~
·a.::=
C"
C.l
~
"C
=
=
--===
.~
e
~
--
...=
r ll
= 5
• 118
Insertion of Parallel Guide Wires Percutaneously
Using the Parallel Drill Guide
When planning where the different guide wires are to be placed,

the possible distances offered by the parallel drill guide should
be taken into consideration. Measured from the centre of the
main hole to the centres of the others, the distance can be 10, 14,
and18 mm.
Note: To prevent loss of reduction, each screw is fully inserted
before starting with the next.
- After insertion of the first guide wire as described above, the
percutaneous sleeve assembly is removed.
- The parallel drill guide is prepared with the drill sleeve,
4.5 mm/2.0 mm, in its outermost 4.5 mm hole marked 0. This
combination is placed over the first inserted guide wire.
- A second 4.5 mm/2.0 mm drill sleeve and 2.0 mm trocar are
inserted into one of the other three holes in the parallel drill
guide. After stab incision the trocar is pressed onto the near
cortex.
- The trocar is removed and a threaded guide wire inserted to
the appropriate depth with the small air drill. Any bending
force on the first guide wire must be avoided, as this will affect
the parallel alignment of the holes.
- Further guide wires can be inserted using this technique. Any
previously inserted guide wire can be used in the outermost
hole for parallel placement of the next wire.
- The remaining steps for insertion of the screws are performed
through the protection sleeve, 11.0 mm/8.0 mm, as described
above.
- The anteversion wire is removed using the small air drill (re-
verse trigger) once correct placement ofthe guide wire is con-
firmed.
Insertion of7.0 mm Cannulated Screws in Femoral Neck

Fractures Using the Parallel Wire Guide, Open Procedure
- After reduction, the anteversion of the femoral neck is deter-

mined by placing a 2.0 mm Kirschner wire or a threaded
guide wire along the anterior aspect of the femoral neck. The
position is confirmed with an image intensifier.
- Using the parallel wire guide, a 2.0 mm threaded guide wire is
inserted as a positioning wire into the centre of the femoral
head parallel to both the anteversion wire in AP and axial
views. The drill should run at maximum speed to minimise de-
flection (Fig. 1). In dense bone pre-drilling of the cortex with
the 2.0 mm drill bit is recommended.
119
•
- Remove the anteversion wire with the small air drill (reverse
trigger) once the correct placement of this positioning guide
wire is confirmed.
- The parallel wire guide is replaced over the guide wire
through any of its central holes until correctly position-
ed.
- A 2.0 mm guide wire is inserted through each of the outer
holes into the subchondral bone of the femoral head, starting
with the most superior hole. Their correct position is con-
firmed with an image intensifier.
- The parallel wire guide and the positioning wire in the centre 2
are removed (Fig. 2).
- The screw length is measured with the cannulated screw mea-
suring device. The length measured is the screw length (8 mm
short of the threaded portion of the guide wire) (Fig. 3).
- The cannulated drill bit, 4.5 mm, and double drill sleeve are
used to drill over the guide wire to the measured depth.
Advance slowly and let the drill bit follow the guide wire.
The calibration on the drill bit can be used to confirm the
depth (Fig.4). Because of the cannulation, it is more suscepti-
ble to breakage than solid drill bits and care must be taken not
to bend or force the drill bit in an axial direction. The reverse
gear must not be used to remove the drill bit, only the forward
gear. Bone debris will otherwise accumulate in the cannula- 3
tion, causing the wire to be inadvertantly removed, as its

threaded hold in the femoral head will be unscrewed.
- The cannulated tap is passed over the guide wire and the near
cortex tapped (Fig. 5). In dense bone virtually the entire non-
threaded length of the wire may have to be tapped. The per-
cutaneous 11.0 mm/8.0 mm protection sleeve, or the stan-
dard 6.5 mm tap sleeve, can be used to protect the tissue.
- The large cannulated screwdriver is used to insert the select-
ed screw over the guide wire. The thread length of the screw
must be selected such that it engages only the head fragment.
A washer may be used to prevent the screw head from crack-
ing the cortex and sinking into the bone (Fig. 6).
"'
~
=-=
·=.c
1.1
~
-==
=
--==
=
.~
e
~
-==
...
...."' 5
6
• 120
- The correct position of the screw is confirmed with an image
intensifier.
- The guide wire is removed using the small air drill (reverse
trigger) and discarded (Fig. 7).
- The remaining screws are inserted using the same technique
(Fig. 8).
Reinsertion of an Inadvertantly Removed

Threaded Guide Wire
The drill bit is disconnected from the small air drill and reinsert-
ed into the drilled hole with the guide wire inside. The guide
wire is then advanced into position with either another guide
wire or the cleaning stylet.
6.6.1.5 Instruments for Insertion and Removal

of Cannulated Screws
Instruments for percutaneous insertion of 7.0 mm cannulated

screws
II
I ..,
j '
121 •
Instruments for insertion of7 .0 mm cannulated screws using the
parallel wire guide
Instruments for removal of 7.0 mm cannulated screws.
The 7.0 mm cannulated screws are removed using the regular

large hexagonal screwdriver and large holding sleeve. The
hexagonal recess must be freed from any debris before the
screwdriver is engaged. The holding sleeve is used when trac-
tion is needed, i.e. for partially threaded screws. The reverse-
cutting flutes in the thread facilitate removal even in dense
bone.
The 4.5 mm cannulated screw is used primarily in malleolar

fractures, in fractures of the proximal and distal humerus, patel-
lar fractures, and fractures of the calcaneus and talus. It may
"'
Q,l
also be used for certain fractures of the pelvis, the acetabulum
;. and of the tibial plateau.
·a
.c
The 4.5 mm cannulated screws and the instruments necessary
~ for their application may be obtained in either a graphic case, a
"C sterilising tray or in an aluminium case.
=
--=e
~
.s=
~
Q,l
-..=e
"'
• 122
6.6.2.1 Instruments
Threaded Guide Wire, 1.6 mm Diameter, 150 mm
The 1.6 mm guide wire, coloured brown for easy identification,

has a spade point tip for better cutting ability and smooth inser-
tion using the small air drill. It is inserted after reduction at the
site where the screw is to be placed. The 5 mm threaded tip has
to be anchored safely in the far cortex for correct measurement.
The position is confirmed by image intensification. The drill
guide should be used so as to avoid creeping of the wire on the
bone surface. In hard juvenile bone pre-drilling with a 1.5 mm
drill bit is recommended.
The guide wire must not be damaged during use.
Drill Bit, 1.5 mm
The 1.5 mm drill bit, 110 mm/85 mm, is used to pre-drill a hard
cortex before inserting the threaded guide wire, 1.6 mm.
Cannulated Drill Bit, 3.2 mm, Four-Fluted
The 3.2 mm, four-fluted cannulated drill bit, 170 mm/140 mm,
has a cannulation of 1.7 mm to fit over the 1.6 mm guide wire.
The four cutting edges prevent skidding. The drill bit has a quick
coupling end to fit into the small air drill. The drill bit is used to
pre-drill for the 4.5 mm cannulated screw. Because of the can-
nulation the drill bit must be used with great care so as to avoid
breakage. Cleaning of the cannulation with the cleaning stylet is
imperative to prevent binding about the wire.
Percutaneous Sleeve Assembly
- The protection sleeve, 9.5 mm/7.0 mm, 39 mm long, has a han-

dle and is used when measuring and inserting the screw in
percutaneous procedures. It is also used to guide the other
parts of the assembly. The sleeve allows a working depth of
31mm.
- The drill sleeve, 7.0 mm/3.2 mm, 46 mm long, is used inside
the protection sleeve, 9.5 mm/7.0 mm, as a drill sleeve for the
3.2 mm cannulated drill bit.
- The drill sleeve, 3.2 mm/1.6 mm, 52 mm long, inserted into
the two sleeves described above is used a guide for the thread-
ed guide wire to avoid the risk of wire deflection during inser-
tion.
- The trocar, 1.6 mm, 59 mm long, is used within the assembly
when passing it through the soft tissue down to the bone.
123 •
Adjustable Parallel Wire Guide
The adjustable parallel wire guide is used for parallel placement

of additional guide wires when parallel screws are to be placed.
The sleeve can be removed and placed in the desired position
within the slot. It is locked by turning the knurled top.
The double drill sleeve is used when drilling and tapping in open
procedures.
Cannulated Countersink, Tip 3.0 mm
The cannulated countersink is used to cut a recess in the bone

for the 4.5 mm cannulated screw head. It has a quick coupling
end to fit the T handle.
T Handle
The T handle, with quick coupling, is used as handle for the

countersink and for the tap.
Cannulated Screw Measuring Device, 4.5 mm
The cannulated screw measuring device can be used separately

in open procedures (or through the protection sleeve,
9.5 mm/7.0 mm in percutaneous applications) to measure the
screw length. It is calibrated such that the threaded portion of
the guide wire (5 mm) is deducted, thus preventing the screw
from penetrating the far cortex. The scale at the end of the de-
vice is used to set the drilling depth if the drill guide with stop
from the 3.5 mm cannulated screw set is used. Some devices are
"'~ made of anodised aluminium and are brown in colour. Care
·a.::
a'
must be taken when cleaning these devices. See Sect. 6.22.4.2
1.1
~
=
"'CC
Cannulated Tap for 4.5 mm Cannulated Screw
--
~
= The cannulated tap is used to cut the thread in dense bone when
·=
~
= necessary. It has a quick coupling end to fit the T handle.
..=e
~
--
The double drill sleeve end, 4.5 mm, is used as a tap sleeve. The
cleaning stylet must be inserted after each use to prevent debris
=
"' from collecting in the cannulation.
• 124
Cannulated Hexagonal Screwdriver
The cannulated hexagonal screwdriver for 4.5 mm cannulated

screws, 3.5 mm in width across flats, is used for insertion of the
4.5 mm cannulated screw over the guide wire. Because of its
cannulation, excessive force should not be applied. Screws
should be removed with a regular large hexagonal screwdriver.
Screw Holding Sleeve
The screw holding sleeve fitting the cannulated hexagonal

screwdriver, 4.5 mm, is self-retaining and holds the screw while
it is being inserted. The sleeve should be disassembled for clean-
ing.
Large Hexagonal Screwdriver Shaft
The large hexagonal screwdriver shaft is recommended to be

used with the T handle for removal of screws if the large hexago-
nal screwdriver is not available.
Cleaning Stylet, 1.6 mm
The stylet should be used frequently to clean all cannulated in-

struments intraoperatively to prevent accumulation of debris in
the cannulation and potential binding of the instruments about
the guide wire.
Screw Forceps
This self-holding screw forceps is used to remove screws from

the screw rack.
1.7 mm cannulation, can be used to prepare a gliding hole for
the fully threaded 4.5 mm cannulated screw. It is four-fluted,
and has a quick coupling end to fit the small air drill.
125 •
Cleaning Brush, 1.75 mm
The brush, made of autoclavable nylon and with a steel shaft, is

used to clean 4.5 mm cannulated instruments.
6.6.2.3 Implants
The 4.5 mm Cannulated Screw, Partially Threaded
- Screw head diameter: 6.5 mm 3.2
- Screw head height: 4.0 mm I
- Hexagonal socket width : 3.5 mm css::
- Core diameter: 3.1 mm ~
- Thread diameter: 4.5 mm t
4,5
- Pitch: 1.75 mm
- Cannulation: 1.75 mm
The cancellous thread finds excellent purchase in the spongy
cancellous bone. The screw is self-tapping and has reverse-cut-
ting flutes to facilitate removal of the screw. Partially threaded
screws in lengths from 20 mm to 72 mm are available. The
threaded portion increases stepwise from 7 mm in the 20 mm
screws to 24 mm in the 72 mm screws. These screws can be ob-
tained in a set together with the necessary instruments. The
screws are compatible with the small fragment plates, because
the size of the screw head has been reduced.
Fully threaded screws in lengths of 20 mm- 72 mm are also
available. See SYNTHES catalogue for details.
Washer, 10 mm Outer Diameter
The washer is used to prevent the screw head from cracking a

thin cortex and sinking into the spongy cancellous bone. The flat
side is placed on the bone, the recessed side against the screw
head.
6.6.2.4 Technique of Insertion of 4.5 mm Cannulated Screws
Percutaneous Insertion of Screws
- The fracture is reduced and temporarily fixed with a Kirsch-

ner wire or with a pointed reduction forceps.
- A stab incision is made and the percutaneous sleeve assembly
inserted through the soft tissue after blunt dissection down to
the bone.
- The trocar is removed and a 1.6 mm threaded guide wire in-
serted to the appropriate depth through the drill sleeve,
• 126
3.2 mm/1.6 mm under image intensification. The drill shoud
be run at maximum speed to minimise deflection while gradu-
ally advancing the guide wire (Fig.l).
- Additional parallel wires may be placed using the adjustable
parallel wire guide as indicated below.
- In dense bone the cannulated countersink may be used
through the 9.5 mm/7.0 mm sleeve to cut a recess in the bone
(Fig.2).
2
- The cannulated screw measuring device is used through the
9.5 mm/7.0 mm protection sleeve to measure the proper
screw length (Fig. 3). The measured depth is 5 mm short of
the threaded guide wire tip (the threaded portion of the wire),
to prevent the screw from penetrating the far cortex.
- The 7.0 mm/3.2 mm drill sleeve is reinserted into the outer
sleeve, and the 3.2 mm cannulated drill bit passed over the
guide wire. The near cortex is drilled, allowing the drill to fol-
low the guide wire. It must not be forced or directed at a dif-
ferent angle. In dense bone the entire length of the unthread-
3
ed part of the wire may have to be drilled (Fig. 4). The drill
guide with stop, with 3.2 mm insert, from the 3.5 mm cannu-
lated screw set can be used (see below). The correct drilling
depth is confirmed with image intensification.
- In dense bone the tap for 4.5 mm cannulated screws is used to
tap the thread in the bone over the guide wire. The double
drill sleeve, 4.5mm, or the protection sleeve 9.5 mm/7.0 mm,
is used for tissue protection (Fig. 5).
- The cannulated hexagonal screwdriver 4.5, without holding
sleeve, is used to insert the selected screw through the
4 9.5 mm/7.0 mm protection sleeve. Because of the cannula-
tion, excessive force should be avoided while tightening
(Fig.6).
- In osteoporotic bone a washer may be needed to prevent the
screw head from cracking the cortex and sinking into the
bone. The washer cannot be placed through the protection
sleeve. This has to be removed to place the washer over the
guide wire before inserting the screw.
- A second screw is inserted either in the place of the previous-
ly inserted Kirschner wire or over a newly placed guide wire
5 (Fig. 7).
- After insertion of the screw, the threaded guide wire is re-
moved using the Jacobs chuck, and the reverse trigger of the
small air drill.
-e
Q,j
"....'
r.I'J
..
~
Q,j
-
~
r.I'J
'C
Q,j
=
eo:
6
=
eo:
u
7
127 •
Insertion of Additional Parallel Threaded Guide Wires
- After placing the first wire as described above, the percuta-

neous sleeve assembly is removed. The fixed sleeve of the ad-
justable parallel wire guide is placed over the first wire.
- The movable sleeve is adjusted to the desired position and the
knurled nut tightened. A separate incision may be necessary.
- Without placing any bending force on the first guide wire,
which would affect the parallel alignment, a second 1.6 mm
threaded guide wire is inserted and its position confirmed
with image intensification.
- Any additional guide wires can be inserted following the
same procedure, using one of the previously inserted wires as
guide.
- To prevent loss of reduction, insert each screw over the guide
wire according to the technique described above before pro-
ceeding to the next screw.
6.6.2.5 Instruments for Insertion and Removal of 4.5 mm

Cannulated Screws
Instruments for insertion of 4.5 mm cannulated screws
·a= Instruments for removal ofthe 4.5 mm cannulated screw: When

-=
1,; necessary, the 4.5 mm cannulated screws are removed using the
~ regular, large hexagonal screwdriver. The screw head must be
"C
=
=
cleared of all debris prior to removal.
=
Q
·-=
....=
=
s
~
--=
...=
"'
• 128
The 3.5 mm screw finds application in fractures of the carpus,

L L metacarpals, and metatarsals. It may also be used in osteochon-
dral fractures, epiphyseal fractures in children and for ligament
fixation. The screw is compatible with the 2.7 mm stainless steel
implants and some 3.5 mm implants, i.e. small T plate, clover-
leaf plate.
The 3.5 mm cannulated screws and the instruments necessary

for their application may be obtained in a graphic case, a sterilis-
ing tray, or an aluminium case
6.6.3.1 Instruments
Threaded Guide Wire, 1.25 mm, 150 mm
The guide wire has a self-cutting spade point tip. This wire is in-
serted as guide wire where the 3.5 mm cannulated screw is to be
placed. Its position is confirmed with image intensification. The
5 mm threaded tip should be well anchored in the far cortex be-
fore drilling.
The 2.7 mm, four-fluted cannulated drill bit, 160 mm/130 mm, is
used to drill the thread hole over the 1.25 mm guide wire for the
3.5 mm cannulated screw. The four cutting edges prevent skid-
ding when cutting at angles. lt has a quick coupling end and con-
nects to the small air drill. Because of its 1.35 mm diameter can-
nulation the drill bit is more susceptible to breakage than solid
drill bits. Excessive force and bending must be avoided. The
cannulation must be free of any debris before use to prevent
binding about the wire. T he cleaning stylet must be inserted to
clear the cannulation after each use.
----------------~--~0
I
Double Drill Sleeve, 2. 7 mm/1.25 mm
The 2.7 mm double drill sleeve is used as a drill sleeve for the
1.25 mm guide wire, and at the other end for the 2.7 mm cannu-
lated drill bit.
129 •
The 3.5/2.5 mm double drill sleeve is used as protection sleeve

for the cannulated tap and drill bit 3.5 mm.
Drill Guide with Stop, 3.5 mm/2. 7 mm
The drill guide with stop, with two inserts, is used as a drill guide
for drilling to a predetermined depth. The inserts have diame-
ters of 2.7 mm and 3.5 mm. They can be screwed into the han-
dle. To set the drilling depth the drill bit which has been selected
is inserted into the corresponding size guide until its quick cou-
pling end rests on the drill guide. It is then slid into the end of the
measuring device. The knurled nut is loosened and the threaded
end turned until the protruding drill bit length corresponds to
the drilling depth. The nut is tightened in this position.
Cannulated Countersink, 2.4 mm Tip
The cannulated countersink has a quick coupling end to fit the

handle with quick coupling. It is used to cut a recess in bone to
accommodate the screw head.
Handle with Quick Coupling
The quick-coupling handle connects with the cannulated coun-

tersink and tap. Thanks to the rotating handle it rests in the
palm and can be gently turned with two fingers.
Cannulated Screw Measuring Device, 3.5 mm m !.llii'"rl:lln~~mciJt""~

,11°1!tT~r~-{l~~;~l". . . .~' ._.~,
The cannulated screw measuring device is used to determine

the screw length. It measures 5 mm short of the guide wire tip
(the length of the threaded portion of the wire), preventing the
screw from penetrating the far cortex. The other end can
"'~ be used in combination with the drill guide with stop,
.:r 3.5 mm/2.7 mm, to set the drilling depth as described above.
-5= Some devices are made of anodised aluminium and are silver in
~ colour. Care must be taken when cleaning these devices. See
1 Sect. 6.22.4.2.
....=
.~
.s
=
s
Qjl
....=
...
....=
"'
• 130
Cannulated Tap for 3.5 mm Cannulated Screws
The cannulated tap, 146 mm/61 mm, is used to cut the thread in
dense bone. It has a quick coupling end and connects to the han-
dle with quick coupling. The cleaning stylet must be inserted af-
ter each use to prevent debris from collecting in the fine cannu-
lation.
Small Cannulated Hexagonal Screwdriver
The small cannulated hexagonal screwdriver, 2.5 mm in width

across flats, is used to insert the 3.5 mm cannulated screw over
the threaded guide wire. lt has a groove in the shaft to accept the
small holding sleeve. Because of the cannulation excessive force
must be avoided to prevent damage to the tip. Screws should be
removed with the solid small hexagonal screwdriver: The small
hexagonal screwdriver shaft and quick coupling handle can be
used as an alternative.
Small Holding Sleeve
The holding sleeve is self-retaining and holds the screw safely

while being inserted. It connects with small hexagonal screw-
drivers with a grooved shaft. The sleeve should be disassembled
for cleaning.
Small Hexagonal Screwdriver Shaft
The small hexagonal screwdriver shaft, 2.5 mm in width across

flats, connected to the handle with quick coupling can be used
for removal of screws.
Screw Forceps
The screw forceps is self-holding and used to remove screws

from the screw rack.
Cleaning Stylet, 1.25 mm Diameter
The stylet is used for cleaning cannulated instruments intra-

operatively and after surgery.
131
•
has a 1.35 mm cannulation to fit over the 1.25 mm guide wire. It
has four cutting edges and a quick coupling end.lt is used to pre-
drill a gliding hole for the fully threaded 3.5 mm cannulated
screw, if necessary.
Cleaning Brush, 1.35 mm Diameter
The brush is used for cleaning the cannulated instruments. It has

bristles of autoclavable nylon on a steel shaft.
6.6.3.3 Implants
The 3.5 mm Cannulated Screw
- Screw head diameter: 5.0 mm
- Screw head height: 2.0 mm
- Hexagonal head recess: 2.5 mm 2.5
- Shaft diameter: 2.5 mm 2.7
- Core diameter: 2.5 mm [!IIi \iii f.\i;l
3.5
- Pitch: 1.25 mm
- Cannulation: 1.35 mm
The low profile of the screw head is advantageous when used for
fractures near an articular surface. The tapered tip facilitates in-
sertion; the reverse-cutting flutes aid removal.
The screws are available partially threaded in lengths from
10 mm to 50 mm in 2 mm increments. The threaded portion of
the screws increases stepwise from 5 mm in the 10 mm screws to
16 mm in the 50 mm screw. Fully threaded screws are available
in lengths of 10 mm to 50 mm, in 2 mm increments.
"'~
·2' Washer, 7.0 mm 0
.:::
(,;
~ The washer is used to prevent the screw head from cracking a

1 thin cortex and sinking into cancellous bone. The flat side is
=
~
placed on the bone; the recessed side against the screw head .
-e=
.9
~ The holding clip holds the washers.
--..
~
:I
• 132
6.6.3.4 Technique of Insertion of 3.5 mm Cannulated Screws
Image intensification is essential when using this technique.

- The fracture is reduced and held with pointed reduction for-
ceps.
- A 1.25 mm threaded guide wire is inserted at the site where
screw insertion is planned, using the small air drill and the Ja-
cobs chuck. The double drill sleeve, 1.25 mm, is used as a
guide and tissue protector. A second wire is inserted parallel
to the first to prevent rotation of the fragments . The reduc-
tion forceps is removed and the position of the wires con-
firmed with image intensification (Fig.l ).
- The length is measured with the cannulated screw measuring
device (Fig. 2).
- The drilling depth is set to the desired depth using the direct
measuring device and drill guide with stop. See figure.
- The assembly is placed over the threaded guide wire and the
drilling performed until the quick coupling end contacts the
drill guide with stop (Fig. 3).
Note: The drill bit must not be directed but rather allowed to fol-
low the guide wire. It should be removed slowly while running
the drill forward to prevent guide wire pull out. The reverse gear
must not be used as this may unscrew the threaded guide wire
tip.
- In dense bone the cannulated countersink is used to cut are-
cess in the bone. In osteoporotic bone a washer is used in-
stead (Fig.4).
- The cannulated tap is connected to the handle with quick cou-
pling and used to cut the thread in the near cortex. In dense
metaphyseal bone tapping over the entire nonthreaded
length of the guide wire may be necessary. The double drill
sleeve, 3.5 mm , is used as a tissue protector (Fig. 5).
- The 3.5 mm cannulated screw which has been selected is in-
serted over the guide wire with the small cannulated screw-
driver (Fig. 6. Here the old style screwholding sleeve is
shown).
133 •
- The second screw is inserted using the same technique as de-
scribed for the first screw (Fig. 7).
- The threaded guide wires are removed using Jacobs chuck \\
~
and the reverse trigger of the small air drill. Used guide wires
should be discarded (Fig. 8).
6.6.3.5 Instruments for Insertion and Removal of 3.5 mm

Cannulated Screws
)
~ Instruments for removal of the 3.5 mm cannulated screws. If the
.~~::r., screws are to be removed, the regular, small hexagonal screw-
j driver should be used. The small holding sleeve is of great ad-
~
~ vantage if traction is needed for removal, for example, of par-
1 tially threaded screws. It is essential to clear the screw head
socket of debris prior to removal.
--=
~
.~
=
~
e
--..==
~
• 134
6.7 Dynamic Hip Screw and Dynamic Condylar
Screw Instrument and Implant System
The dynamic hip screw (DHS) implant system has been de-
signed primarily for the fixation of trochanteric fractures. It
may also be used for certain subtrochanteric fractures as well as
for selected basi-cervical femoral fractures.
The implant is based on the sliding nail principle which allows
impaction of the fracture. This is made possible by the insertion
of a wide diameter screw into the femoral head. A side plate,
which has a barrel at a fixed angle is slid over the screw and fixed
to the femoral shaft. The barrel and the screw each have two
corresponding flats, which allow the smooth shaft of the screw
to slide within the barrel and yet retain rotational stability. Thus,
the femoral head fragment fixed with the screw can be impact-
ed, either deliberately or from weight-bearing.
The correct placement of the implant is essential for the success.
The anteversion of the femoral neck has to be determined with a
guide wire as well as the site of the screw in the middle of the
femoral head with a guide pin. The correct position of the guide
pin must be checked with two-plane radiography. All steps nec-
essary for the insertion of the implant are performed over the
guide pin.
The barrel angle can be predetermined by evaluating the angle
subtended between the femoral neck and shaft axes (CCD, or
collum-centre-diaphysis, angle) of the uninjured side. The 135 o
barrel angle is the most commonly indicated.
The dynamic condylar screw (DCS) is similar to the DHS in its
design and concept. The fixed angle between plate and barrel is
95 ° and the plate is contoured to fit the lateral surface of the dis-
tal end of the femur.
The main indications are fractures of the distal femur and inter-
condylar fractures. It may also be used for certain intertrochan-
teric fractures and very proximal subtrochanteric fractures. Pre-
planning the exact site of the screw is essential also for the
successful application of DCS. For application in the distal fe-
mur the axis of the knee joint as well as the inclination of the
patellar articular surface of the condyles have to be predeter-
mined. Impaction or compression of the fracture is achieved by
using the compression screw.
135 •
6.7.1 DHS and DCS Instruments
For the application of the DHS and the DCS special instru-
ments are necessary. These have to be used correctly and in a
special order to ensure optimal placement of the implant.
DHS/DCS instruments are available in either a graphic case or
in sterilising trays. Implant cases are also available. Basic instru-
ments are necessary for the fixation of the plate to the femur
with the large screws. A graphic case containing DHS instru-
ments as well as the necessary basic instruments is obtainable.
DHSIDCS Guide Pins, 2.5 mm Diameter, 230 mm Long

These pins are the special guide pins to be used when inserting
DHS/DCS screws. They must be straight and absolutely un-
"'
~ damaged when introduced. The threaded tip anchors the guide
·f pin in the subchondral bone.
-5
~ Drill Bit, 2.0 mm
1 This bit 100 mm/75 mm may be used to drill the hard juvenile
--=
.i= cortex before introducing the DHS/DCS guide pin .
e
Clll
Q,l
DHS/DCS T Handle
--="'
...= This handle with a quick coupling connects to the angle guides
and to the DHS/DCS tap.
• 136
DHS Angle Guides, 135 °, 140°, 145 °, and 150 °
These guides allow placement of the DHS/DCS guide pin at the
desired angle in the femoral head. The 135 o angle guide is the
one most commonly used, since it corresponds most closely to
the anatomical neck/shaft angle. The guide is connected to the
DHS/DCS T handle and held against the bone surface while in-
serting the guide pin. The spikes on the foot plate prevent slip-
ping.
DCS Angle Guide

This guide connected to the DHS/DCS T handle aids the inser-
tion of the guide pin at 95 o in the distal femur when placed over
the correct insertion point. The angle guide has spikes to pre-
vent slipping off the bone. The new version has a redesigned
bend, which fits better to the curvature of the bone than the old-
ermodel.
DHS/DCS Direct Measuring Device

This device is used to read off directly the inserted depth of the
DHS/DCS guide pin. Other pins can not be used. Devices made
of anodised aluminium must be cleaned according to the guide-
-
lines made in Sect. 6.22.4.2
e
~
DHS Triple Reamer

This reamer prepares the seat for the screw and for plates with
the 38 mm standard barrel. It consists of three elements: an
~
-=
"'
~
c.
~
8 mm diameter drill bit for the screw, a reamer head for the bar- .5
-==
"CC
rel and the conical barrel/plate junction, and a locking nut. To ~
assemble the three parts, the reamer head is slid onto the drill
--=
~
bit with the set screw aligned with the flat on the drill bit. The 5
reamer head is pushed forward until it engages the notch with 2
the desired depth marking. The nut is then tightened firmly. "'
u
~
Special quick couplings are available to connect the triple ream-
er with either the small air drill, or the universal air drill. Q
"CC
The triple reamer is cannulated allowing reaming over the guide =
~
wire. The cannulation needs special attention when cleaning the
=
~
instrument. See Sect. 6.22.5.1. Q
137
•
This reamer is marked DHS and should not be confused with
the DCS triple reamer.
DHS Short Triple Reamer

This reamer is used in similar manner for plates with 25 mm
short barrel. It consists of the same three elements as the stan-
dard reamer, but the reaming portion is shorter.
DCS Triple Reamer

This reamer is clearly marked DCS and should only be used to
ream for DCS. The drill and the locking nut are the same as for
the DHS triple reamer. The reamer, however, is shorter and has
no conical section.
DHS!DCSTap
This is used to tap for the 12.5 mm DHS/DCS screw in juvenile
bone. Before use the short centring sleeve is slid on, and the
DHS/DCS T handle connected. Tapping is done over the guide
wire. The tapped length can be read on the calibrated shaft.
Centring Sleeve for DHSIDCS Tap (Short)

This sleeve is slid on the tap and pushed into the hole, which is
reamed to the barrel size. The sleeve centres the tap during tap-
ping. The window allows the tapping depth to be read. The gold-
en coloured sleeve is made of anodised aluminium and care
must be taken when it is cleaned. See Sect. 6.22.4.2
Guide Shaft
This shaft is used with the coupling screw to insert DHS/DCS
screws. The ridges should interdigitate with the notches of the
outer end of the screw. Some guide shafts have flats on the side
that align with the flats of the lag screw, when assembled for in-
sertion. This allows positioning the plate correctly, with the flats
of lag screw before pushing the plate in place.
"'~ Coupling Screw

·a This screw is pushed through the guide shaft and screwed into
'5 the DHS/DCS screw for insertion. It is cannulated to allow the
~ assembly to be slid over the guide pin.
-=;
Note: This assembly should not be used for extraction.
=
-=
Q
i DHSIDCS Wrench
-....=
~ This wrench is necessary for the insertion and the extraction of
the DHS/DCS screw. For insertion the long centring sleeve is
~ pushed onto the wrench. The screw, assembled with the guide
• 138
shaft and the coupling screw, is then slid into the wrench. The
flat sides of the screw should match the internal flats of the
wrench to allow visualisation of the screw end through the small
window. To insert the screw the complete assembly is slid over
the guide pin, the centring sleeve pushed into the reamed bone
and the wrench turned clockwise.
To extract a DHS/DCS screw, the wrench is coupled with the
long coupling screw. and positioned such that the flat sides of
the wrench and those of the screw shaft match. The long cou-
pling screw is then screwed into the screw end. By pulling and
turning the wrench anti clockwise the screw can be extracted.
Centring Sleeve forD HSIDCS Wrench (Long)

This sleeve is pushed onto the wrench to centre it in the bone
when inserting the DHS/DCS screw. It is made of anodised
aluminium and needs special care when it is cleaned. See
Sect. 6.22.4.2.
DHS/DCS Impactor
This impactor is used to finally seat the DHS and DCS plates by
gentle blows with a hammer. The plastic tip must be seated cor-
rectly in the plate barrel or else it may break. The tip is inter-
changeable. A pin is inserted in the hole of the tip to unscrew it.
~=-=,...----~=------~''-l Long Coupling Screw

This screw is necessary for the extraction of DHS/DCS screws.
It is pushed through the wrench and then screwed into the end
of the DHS/DCS screw. The screw end should be free of debris
before attempting connection with the long coupling screw. By
pulling and turning the wrench anticlockwise, the screw can be
extracted.
Quick Coupling for Small Air Drill

This is necessary to connect the DHS or DCS triple reamer to
the small air drill.
Quick Coupling for the Universal Air Drill

This is necessary to connect the DHS or DCS triple reamer to
the universal air drill.
139 •
Combined DHSIDCS Wrench
This wrench has recently been developed to facilitate the inser-
tion of a DHS/DCS screw and plate. The wrench has the same
outer diameter as the screw shaft. It is coupled with a long cou-
pling screw, which has a locking spring to prevent it falling off.
The selected DHS or DCS plate is slid over the wrench, and the
coupling screw tightened in the selected DHS/DCS screw, until
the cams and the notches interdigitate. An open centring sleeve
is placed and locked over the wrench. The assembly can then be
used for insertion of both screw and plate simultaneously. A
side impactor is used to finally seat the plate without having to
disassemble the instruments.
Any disimpaction at the fracture site can be reduced by gentle ~~
pull on the wrench while impacting the plate. ~llllil~=--·~
6.7.2 DHS/DCS Implants
DHSIDCS Screws
These screws are designed for insertion in both the distal and
the proximal femur. The screw has a smooth shaft with two flat
sides and is partially threaded. The thread is tapered at the tip
and has a reverse cutting flute for easier extraction. The two flat
sides of the shaft correspond to the two flats inside the plate bar-
rel, enhancing rotational stability. The screw is cannulated and
has an inside thread at the outer end for the compression screw
and two notches for coupling with instruments for insertion and
extraction.
The screws are available in lengths from 50 mm to 145 mm, in
5 mm increments
- Thread length: 22 mm
"' - Shaft diameter: 8 mm
...=
~
C"'
=
.c:
o:.l
~
-== DHS/DCS Compression Screw
=
--
= This can be screwed into the end of the DHS/DCS screw to
·== achieve final impaction. It may also be used in unstable frac-
= tures to prevent disengagement of the screw from the plate bar-
...-
=
~
rel in non-weight-bearing patients. When using the compres-
2 sion screw in osteoporotic bone, great care must be taken not to
=
"' strip the thread of the DHS/DCS screw within the bone .
• 140
The compression screw is left in place in a DCS, in a DHS re-
moval is optional. It is 36 mm long and has a hexagonal socket to
fit the large hexagonal screwdriver.
DHS Plates, Standard Barrel, 38 mm

This is the standard plate with barrel angles 135 °, 140°, 145 °,
and 150°. Most commonly indicated is the plate with 135 °.
Greater barrel angles may offer biomechanical advantages in
unstable cases: i.e. better gliding characteristics, reduction of
bending stresses on plate/barrel junction. Correct placement of
the implant becomes technically more difficult as barrel angles
increase (see Regazzoni et al. 1985).
Two flats within the barrel correspond to the flat sides of the
DHS/DCS screw. Thus, rotation of the screw within the barrel is
prevented.
The side plate has staggered DCP holes accepting 4.5 mm
screws.
The DHS plate 135 o is available with 2, 4, 5, 6, 8, 10, 12, 14, or 16
holes, in lengths from 46 mm to 270 mm.
DHS plates 140 o and 145 o are available with 4, 5, or 6 holes in
lengths from 78 mm to 110 mm.
DHS plate 150 ° is available with 2, 4, 5, 6, 8, 10, or 12 holes, in
- Profile: See figure
L
- Thickness: 5.8mm
- Width: 19 mm
- Barrel outside diameter: 12.6mm
DHS Plate 135 °, 25 mm Barrel

These plates are rarely indicated, but may be necessary to use in
-
unusually small femurs. If a long impaction distance is expected
and the screw might "run out of glide", the short barrel plate
e
~
may be chosen. It is sometimes used in the fixation of a medial "'

~
ri:J
displacement osteotomy. The plate is applied in similar manner
i
!
to the standard DHS, but the short reamer must be used.
The short barrel plates are available with 4, 5 or 6 holes, in
-==e
"CC
lengths from 78 mm to 110 mm. The other dimensions are simi-
~
lar to those of the standard plate.
-=
~
2
"....'
ri:J
u
Q
=
"CC
~
'JJ
=
Q
141 •
DCS Plates, 95 a
These plates have a barrel length of 25 mm with two internal
flats to guide the screw. The plate has staggered DCP holes and
is fixed with 4.5 mm cortex screws. The two round holes near the
plate/barrel junction accept 6.5 mm cancellous bone screws.
The plates are available with 6, 8, 10, 12, 14, or 16 holes, in
- Thickness: 5.4mm
- Width: 16 mm
DHS Trochanter Stabilising Plate ...-.

" ("'"'
r·
This is a recently developed plate, which may be used in con-
junction with the DHS system for the treatment of unstable
pertrochanteric fractures with medial comminution, or frac-
tures with a completely detached greater trochanter. The plate
is applied over the DHS side plate, after this has been fixed to
the femur with a 4.5 mm cortex screw in the second plate hole.
The head portion may be contoured to the shape of the
trochanteric area using two bending irons or pliers. The plate is
fixed to the femur with three screws, which also pass through the
DHS side plate holes. The plate has a large hole at the site of the
DHS screw to allow gliding.
In the plate hole proximal to this an antirotation cancellous
bone screw, 6.5 mm can be inserted parallel to the DHS screw.
The greater trochanter is fixed either by 4.5 mm cortex screws
through the larger holes, or by cerclage wiring through the
smaller holes in the head portion.
- Profile : See figure
- Thickness: 1.5mm
- Width head : 39 mm
- Width shaft: 22 mm
- Plate length: 148 mm
"' DHS Locking Device

·ag.
~
This is a device which can be inserted in the DHS temporarily to

-8 block the telescoping effect in the plate barrel. This may be indi-
~ cated in young patients with completely detached head-neck
a
"CS
fragment, where bony support has to build up before gliding of
--e
.= the DHS can be allowed .
~
The blocking effect is produced by the spring-loaded wires near
=
= the screw head. The telescoping ability is reintroduced when the
~
-.s..=
screw is removed.
The screw can be inserted with the torque-indicating screw-
"' driver.
• 142
6.7.3 Technique of Application
6.7.3.1 Application ofDHS
The patient is positioned supine on either a regular or a fracture

table. An image intensifier is essential.
- The fracture is reduced and temporarily fixed with Kirschner
wires, or held in reduction using the traction facility of the
fracture table.
- The anteversion of the femoral neck is determined by placing
a Kirschner wire along the front of the neck using the
DHS/DCS angle guide. The wire is gently hammered into the
femoral head (Fig. 1).
- The correct DHS angle guide is positioned against the middle
of the femoral shaft, such that its tube is pointing toward the
centre of the femoral head.
- The lateral cortex is opened with the 2.0 mm drill bit. The
direction of this hole, however, tends to influence the direc-
tion in which the guide pin can go. Increasing the drill hole
to 3.2 mm allows a greater choice of direction for the guide
pin (Fig. 2).
- The DHS/DCS guide pin is drilled into the femoral head
through the DHS angle guide, parallel in the coronal plane to
the previously inserted anteversion Kirschner wire. The
threaded end of the guide pin should be anchored in the sub-
chondral bone (Fig.3). The position of the pin is checked with
the image intensifier (Fig. 4). It should lie in the centre both in
anteroposterior and in axial views (Fig. 5). An incorrectly
placed pin must be changed.
e
....
~
"'......
....
r:rJ
=
=
-=
"S.
e
....=
"C
=
e
.....=
~
-"'
=
r:rJ
u
Q
=
"C
=
r:rJ
::c
Q
143
•
- The direct measuring device is slid over the guide pin and the
inserted depth measured. The calibration provides a direct
reading (Fig. 6).
- The anteversion Kirschner wire is removed.
- The DHS triple reamer is set at the desired reaming depth:
5-10 mm less than measured.
- A special quick coupling is used to connect the reamer to the
air drill. The reamer is slid over the guide pin and reaming
started. The speed should be diminished when each portion
of the reamer enters the lateral cortex to avoid further dam-
age to the bone. The reamer drills for the screw, reams for the
barrel and countersinks for the plate/barrel junction.
- The reamer must "follow" the guide pin, or else it would dam- 6
age it or push it forward into the acetabulum (Fig. 7).
- The reamer is carefully withdrawn leaving the guide pin
in place. If the guide pin is inadvertently removed it must
be repositioned. By placing a screw retrograde into the
short centring sleeve the guide pin can be accurately rein-
serted.
- In young patients the dense cancellous bone may have to be
tapped. The short centring sleeve is mounted on the tap and
the T handle attached.
- When tapping, the centring sleeve is pushed into the bone to
prevent "wobbling" and damage of the thread in the bone.
The tapping depth (i.e. screw length) can be checked through
the window of the centring sleeve (Fig. 8).
- The selected screw, 5- 10 mm shorter than the guide pin depth
measurement, is assembled with the guide shaft and the cou-
pling screw.
- The long centring sleeve is pushed onto the DHS/DCS
wrench and the screw assembly inserted.
- To stabilise the assembly, the centring sleeve is seated fully in
the bone. By turning the wrench clockwise the screw is insert-
ed until the zero mark aligns with the lateral cortex. The tip of
the screw now lies 10 mm from the joint surface (Fig. 9). In
rl1
=
~
·a.==-
1:.1
~
"C
=
...==
--==
Q
e
~
-....=..=
rl1
8
• 144
porotic bone, the screw should be inserted additional 5 mm to
increase the holding power. Before removing the T handle, its
handle should be aligned parallel to the long axis of the femur.
This ensures proper placement of the side plate (Fig.lO).
- The T handle and the centring sleeve are removed ; the guide
shaft and coupling screw are left in place (Fig.ll ).
- The selected DHS plate is slid onto the guide shaft assembly
10 and pushed onto the screw (Fig.12).
- After removal of the guide shaft assembly, and guide pin
(Fig. 13), the impactor is used gently to seat the plate on the
bone (Fig.14).
- The side plate is fixed to the femur with 4.5 mm cortex screws :
11
D rilling 3.2 mm, measuring, tapping, and insertion of the
screw (Fig. 15).
- T he remaining screws are inserted using the same technique
(Fig. 16).
12 13
-=
Q,j
-=
"'
.....
(I)
=
-==
Q.
-==
"CC
--==
Q,j
....
"'
• ( I)
u
~
"CC
=
=
(I)
15 16 =
~
145
•
- For further compression of trochanteric fractures, the com-
pression screw may be inserted into the DHS/DCS screw and
tightened with great care to avoid stripping the DHS/DCS
screw thread in the bone. Leaving the compression screw in is
optional.
Example of measurements:
- Length measured 105mm
- Reamer setting 95mm
- Tapping depth 95mm
- DHS/DCS screw length 95mm
6.7.3.2 Application ofDCS in the Distal Femur
Note: A DCS can be used only if at least 4 em of the distal femur

is intact to provide support for the implant. Also, the medial
cortex of the distal femur must be intact or the medial support
reconstituted with a cancellous graft to avoid failure of the im-
plant.
The patient is positioned on a regular table in such a way that
the knee can be flexed through 90 o. Intraoperative radiography
is essential and image intensification preferable.
- The fracture is reduced and temporarily fixed. Intercondylar
fractures are fixed with 6.5 mm cancellous bone screws as lag
screws (Fig.l) taking care to avoid the planned site of inser-
tion of the DCS screw (Fig. 2).
- After reconstruction of the condyles, three Kirschner wires 2 ~=--?"'=~~
are used to determine the correct site for the DHS/DCS
screw.
- First, a Kirschner wire is inserted through the knee joint along
the distal end of the condyles (1) to mark the plane of the 4
tibia-femoral articulation (Fig. 3).
- A second Kirschner wire is inserted anteriorly over the
condyles (2) to mark the plane of the patellar surface of the
femoral condyles (Fig. 4 ).
- Thirdly, a DHS/DCS guide pin (3) is inserted with the air drill
(Fig. 5) at the predetermined point of insertion parallel to
wire (1) in anteroposterior view (Fig. 6), and parallel to the
anterior wire (2) in axial view (Fig. 7).
5
• 146
- The threaded end should be anchored in the medial cortical
bone. This pin determines placement of the DCS implant and
must be correct. Misplacement can result in varus/valgus or
rotational malalignment.
- Correct placement is verified with image intensifier.
- The Kirschner wires are removed.
- The inserted depth is measured with the direct measuring de-
vice (e.g. 85 mm) (Fig.8).
- The DCS triple reamer is assembled: The reamer head
marked DCS is slid onto the drill bit, with the set screw
aligned with the flat on the drill bit. When the reamer head
8 engages the notch with the desired reaming depth (e. g.
75 mm), the nut is tightened firmly.
- The DCS triple reamer is connected to the special quick cou-
pling and then to the air drill.
- The triple reamer is slid over the guide pin and reaming start-
ed. The speed is diminished when each portion of the reamer
enters the lateral cortex. Two steps are prepared: the hole for
the screw, and the seat for the plate barrel. The guide pin must
not be damaged when drilling (Fig. 9).
- If the guide pin is inadvertently withdrawn when removing
the triple reamer, it must be reinserted. The short centring
sleeve pushed into the bone and a screw inserted in a retro-
grade position, makes reinsertion easy. The guide pin should
remain in place until the side plate has been attached.
- In young patients with dense bone, tapping may be necessary.
The short centring sleeve is mounted on the tap and the T
handle connected. The centring sleeve is pushed into the
bone to avoid "wobbling" when tapping. The tapping depth
(i.e. reamed depth; e. g. 75 mm) is checked through the small
window in the sleeve (Fig.lO).
- A DHS/DCS screw 5 mm shorter than the reamer setting
(e.g. 70 mm) is chosen. The screw is connected to the guide
shaft/coupling screw assembly. The notches of the screw must
interdigitate with the ridges of the guide shaft.
147 •
- The long centring sleeve is pushed onto the DHS/DCS
wrench and the screw assembly inserted. The screw end
should be visible through the window in the wrench. While in-
serting the screw over the guide pin the wrench is centred in
the bone with the long centring sleeve (Fig. 11 ). The screw is
inserted until the 5 mm mark on the wrench aligns with the
lateral cortex. This leaves a 5 mm gliding capacity in the bar-
rel when the fracture is compressed.
- In osteoporotic bone the screw may be inserted to the 10 mm
mark, enhancing the grip of the screw.
- The handle of the wrench should be aligned with the long axis
of the femur before being removed (Fig.12). 11
- The wrench and the centring sleeve are removed; the guide
shaft/coupling screw are left in place at this stage.
- The barrel of the selected DCS plate is pushed over the screw
assembly until the flat sides align (Fig.13).
- After removal of the guide shaft/coupling screw, the guide pin
is removed using the Jacobs chuck in the small air drill (re-
verse trigger) (Fig.14).
- The plate is gently seated with the impactor. The cortex at the
proximal rim of the insertion hole may have to be chiselled to 12
seat the plate further (Fig.15).
- The compression screw is used carefully to compress the frac-
ture without stripping the thread in the bone. It also locks the
plate to the condylar screw (Fig.16).
13
"'
~
·a.c=
C"
1.1
~
"C
=
=
--
=
.~
=
=
16
e
~
-.se
"'
• 148
- Two 6.5 mm cancellous bone screws are inserted through the
two distal plate holes to increase the interfragmentary com-
pression and provide rotational stability of the implant in the
distal fragment. Drilling 3.2 mm (Fig. 17), measuring, tap-
I
ping, and insertion of a long threaded 6.5 mm cancellous
bone screw (Fig.18).
- For the final reduction of the condylar complex and the
femoral shaft, the articulated tension device may be used. It is
attached first in distraction mode for indirect reduction, and
then hooked in the last plate hole for axial compression.
A 4.5 mm cortex screw is used to fix the device to the bone.
The bolt of the device is tightened using the open end wrench
(Fig.19).
17 - Before the articulated tension device is removed, at least
three 4.5 mm cortex screws should have been inserted
through the plate. If a screw is crossing the fracture it has to be
inserted as a lag screw: Drilling 4.5 mm for the gliding hole,
then 3.2 for the thread hole, measuring, tapping, and insertion
of the screw (Fig. 20).
- Insertion of the remaining screws (Fig. 21 ).
Example of measurements:
- Length measured 85mm
- Reamer setting 75mm
- Tapping depth 75mm
- DHS/DCS screw 70mm
18
..."'e
~
...=
~
tJ:J
~
Q.
....e
=
'"C
...=
~
e
~
......=
"'
....=
tJ:J
19
u
20 21 Q
=
'"C
~
tJ:J
=
Q
149
•
6.7.3.3 Application ofDCS in the Proximal Femur
The technique of application of the DCS in the proximal femur

is similar to the technique described above for the distal femur.
The positioning of the guide pin in the femoral neck has to be
correct to ensure proper placement of the implant.
A Kirschner wire is inserted to determine the anteversion of the
femoral neck (see Fig. 1, p. 143). The condylar guide (85 °) is
then used to place the DHS/DSC guide pin correctly in the
greater trochanter. The wire should also be parallel to the ante-
version wire. The point of entry is at the junction of the ante-
rior and middle third of the trochanter massive. The guide pin
should not lie less than 1 em from the superior cortex, and its tip
approximately 2 em short of the articular surface in the lower
part of the femoral neck.
For preparation and insertion of the DCS, see illustrations.
6.7.4 AO/ASIF Instruments for Application and

Removal ofDHS and DCS
Instruments for the application of DHS
Instruments for the application of DCS
• 150
Instruments for the removal of DHS and DCS
'I
Procedure:
- After cleaning the screw head recess of debris the plate fixa-
tion screws are removed with the large hexagonal screwdriv-
er. Likewise an eventual compression screw, and the plate are
removed.
- The DHS/DCS wrench is assembled with the long coupling
screw and placed on the DHS/DCS screw end with the flats
aligned. The coupling screw is screwed in the DHS/DCS
screw end.
- By pulling the assembly and turning anticlockwise, the
DHS/DCS screw can be removed.
6.7.5 References
- e
~
Regazzoni P, Riiedi T, Winquist R , Allgover M (1985) The dynamic hip -=

"'
~
~
--
C'l:l
screw implant system. Springer, Berlin Heidelberg New York c.
e
"C
=
C'l:l
=
..=e
--
~
=
"'
u
~
Q
"C
=
C'l:l
=
~
151 •
6.8 Angled Blade Plates and Instruments
Angled blade plates were developed for the fixation of proximal

and distal femoral fractures. Later osteotomy plates with differ-
ent angles were introduced. All angle blade plates are of one-
piece construction with a fixed angle between shaft and blade.
L
The fixed angle increases the strength of the implant and makes
it less susceptible to corrosion. A further advantage of the fixed
angle is the possibility of accurate placement of the plate in
osteotomies.
Angled blade plates with 95 o and 130 o angles are mainly used
for fracture fixations. Osteotomy plates of various angles are
available in sizes for both adults, adolescents, children and
infants.
The blade of the plates for adults has aU-cross-section, which
provides high strength with minimum bone displacement. An-
gle blade plates for small adults, adolescents, children and in-
fants have a T-shaped blade cross-section. Although sharp at
the tip, the seat of the blade must be prepared with a seating - L
chisel with the corresponding cross-section.
- I I
-
The shaft of the plate is slightly thicker than that of the straight,
broad plate and can withstand higher stresses. The dynamic
compression holes are arranged in an offset mode, similar to the
straight broad plates. These holes accept 4.5 mm cortex screws;
the round holes in some types of plates will accept 6.5 mm can-
"'~ cellous bone screws. For axial compression of fractures of the
·a' femur, it is often necessary to use the articulated tension device
'5 instead of the self-compressing DCP holes.
~ Due to its special design, the insertion of the angled blade plate
"CS
; requires great precision. Preoperative planning is essential to
= determine the exact placement of the plate. The blade must be
-e
.~
-; correctly placed in both the frontal and the sagittal planes, and
§:l the shaft must line up with the axis of the femur. The anatomical
landmarks must be known and guide wires inserted for orienta-
=
~ tion at the time of surgery. Misplacement of the plate may lead
.S to varus, valgus or rotational deformities.
• 152
6.8.1 Angled Blade Plate Instruments
The instruments for angled blade plate application can be ob-

tained in either a graphic case or in a sterilising tray. A graphic
case for condylar plates is also available.
6.8.1.1 Standard Instruments
Drill Bit, 2.0 mm

This bit is used to pre-drill for the Kirschner wires necessary
when planning the procedure.
Kirschner Wires, 2.0 mm Diameter, 150 mm

These wires are used to mark the different angles when plan-
ning for the insertion of angled blade plates. They are inserted
with the small air drill using the Jacobs chuck.
Triangular and Quadrangular Positioning Plates

These small positioning plates are used to determine the angles
for inserting the Kirschner wires necessary for all angled blade
plate procedures. They help indicate correct angulation of the
seating chisel and to set the angle of the flap of the seating chisel
guide. They are also used to determine correct osteotomy
angles.
Due to their small size, vision is not obscured during insertion of
the Kirschner wires. They can be held with a long forceps.
Condylar Plate Guide

This condylar plate guide is used to determine the best site and
the correct angle for the condylar plate. Its side is an exact nega-
tive of the plate and the angle of 95 o corresponds to that of
the plate.
153
•
Triple Drill Guide
The triple drill guide has a set angle of 130 o and was originally
designed to be used as a drill guide when preparing the seat for
the 130° plate. It has a removable attachment with a ball bear-
ing, which directs the 3.2 mm drill bit or a 3.0 mm Steinmann pin
inserted along the femoral neck. The three holes accept the
4.5 mm drill bit, which is employed to open the cortex.
If slid on to the condylar guide, it can be used as a drill guide for
condylar plates too.
Router, 7 mm Diameter
The router is used to enlarge the three 4.5 mm holes into a slot
before the seating chisel is inserted. It is both front and side cut-
ting. It is available with both a quick coupling end to fit the small
air drill and a triangular end to fit the Jacobs chuck.
Seating Chisel, 320 mm, U Profile

The seating chisel is used to cut the channel for the angled blade
plates. Its U-shaped cross-section corresponds to that of the
blade. The engraved millimetre scale to 110 mm indicates the
depth of insertion. The tip of the chisel is ground such that it will
not bite into the calcar when inserted obliquely. The sides are
ground to converge slightly, which enhances the centring of the
chisel in the femoral neck. Resharpening of the chisel must
therefore be done by the manufacturer.
A 500-g hammer is used for insertion, the slotted hammer for
extraction of the seating chisel.
The long seating chisel gives enough "driving way" for removal
from dense bone.
Chisel Guide
The chisel guide is slid onto the seating chisel from the front and
used to control the rotation of the chisel about its long axis. The
~ flap can be set at the same angle as the blade plate and the
§.. condylar plate guide. The locking screw is tightened with the
·s hexagonal screwdriver. When inserting the seating chisel, the
'5 flap of the chisel guide should be in line with the long axis of the
~
-c femur to avoid flexion/extension malposition.
=~
§ Slotted Hammer
~
-="a The slotted hammer is used to adjust and maintain the orienta-
-.s..
tion of the seating chisel during insertion. It is also employed to
' IJ
extract the chisel. If necessary, it can be used to remove angled
blade plates mounted with the inserter - extractor.
• 154
Inserter- Extractor
The inserter- extractor has a notched head into which the plate
is mounted for insertion and, if necessary, for extraction. It must
be placed as close as possible to the shoulder of the plate. The
handle and the blade of the plate should be on horizontal line:
after loosening the bolt, the notched head is moved into the cor-
rect position, the plate inserted and the bolt tightened firmly
with the combination wrench.
Impactor
The impactor is used to finally seat the plate in close contact
with the bone. Its tip fits into the depression near the shoulder of
the plate.
DCP Hip Drill Guide, 4.5 mm

The drill guide, neutral (green) and load (load), is used with the
3.2 mm drill bit to drill for the 4.5 mm cortex screws necessary
for the fixation of the angled blade plate.
Its 60 mm length allows the handle to extend beyond the mus-
cles in the hip region.
Seating Chisel, 260 mm, T Profile

The seating chisel is used to prepare the seat for angled blade
plates for small adults, adolescents and children. The T cross-
section corresponds to that of the plates. It is used with the chis-
el guide for control of the rotation. The chisel has a blade length
with a full T profile of 80 mm.
Small Seating Chisel, 260 mm, T Profile

The small seating chisel is used to prepare the track for the blade
ofthe infant hip plate. It has aT-shaped cross-section that corre-
sponds to that of infant hip plates. The shaft accepts the chisel
guide, which is necessary to control rotation during insertion of
the seating chisel. The blade length with full T profile of this
chisel is 30 mm.
Inserter - Extractor
The inserter - extractor with adjustable head can be set in two
positions for insertion of angled blade plates, for small adults
and adolescents (marked A) and for children.
Once mounted, the plate is locked in place by tightening the bolt
with the combination wrench.
155
•
Small Inserter- Extractor
The small inserter- extractor can hold both the infant hip plate
and the bifurcated plate for insertion. The bolt is carefully tight-
ened with the combination wrench. Since infant bone is quite
soft, the insertion of the infant hip plate may be possible without
hammering the inserter.
6.8.1.3 Obsolete Instruments
Large triangular and quadrangular positioning plates have been

replaced by the small positioning plates, since the large ones of-
ten obscured the field of vision.
The drill guide for round hole plates has been replaced by the
double drill sleeve, 4.5 mm/3.2 mm, which is now used when the
two round holes in the condylar plates are fixed with large can-
cellous bone screws.
6.8.2 Angled Blade Plates
Condylar Plate, 95 °, U Profile

The condylar plate was primarily designed for the distal femur
in adults. The 95 ° angle was chosen to maintain the physiologi-
cal angle between the femoral shaft and the knee joint, when the
plate is inserted parallel to the knee joint. The condylar plate
has found increasing use also in proximal femur fractures. Then,
the plate has to be inserted through the anterior half of the
greater trochanter into the centre of the neck, and parallel to the
neck axis in the coronal plane. The best position of the plate is
just below the point of the trabecular intersection. Guide wires
are used to determine the different planes. X-ray or image in-
tensification is used only to verify the definitive insertion of the
seating chisel.
Condylar plates are available with 50, 60, 70, and 80 mm blade
lengths. The shaft has 5, 7, 9 or 12 holes. The two round holes
nearest the blade accept the 6.5 mm cancellous bone screws .
.J
.:
!:sear:~~:~~o~~~ ~e~:i~~o~~~c:.m cortex screws; the last one
~ Important dimensions :
1= - Thickness:
- Width:
5.6mm
16 mm
-==
.i
.... - Hole spacing: 16 mm
- U profile blade: 6.5- 16 mm
~
i
....ll
• 156
Condylar Plate, 95 o, T Profile
The condylar plate is to be used in small adults for fractures of
the distal and proximal femur as for intertrochanteric os-
teotomies, where the U profile would be too wide and might
cause breakage of the neck. Four different blade lengths are
available: 40, 50, 60, and 70 mm. The shaft is slightly smaller
than that of the regular plate, but has DCP dynamic compres-
sion holes accepting 4.5 mm cortex screws. The two holes near-
est the blade are round and accept 6.5 mm cancellous
screws.The plates are available with 5, 7 and 9 holes and blade
lengths of 40, 50, 60, and 70 mm. A seating chisel with the same
T profile is necessary to prepare the seat of the blade.The in-
serter - extractor for large plates is used for insertion of the
plate.
The preplanning of surgery and the insertion and fixation of the
implant are otherwise similar to that of the large condylar plate.
- Thickness: 5.3mm
- Width: 14 mm
- T profile blade: 5- 11.7 mm
Angled Blade Plates, 130°, U Profile

The angled blade plates were developed for intertrochanteric
and for certain subtrochanteric fractures; their use, however,
has declined since the introduction of the DHS. When used, the
preplanning of the procedure is as essential as when using the
condylar plate.
The anteversion of the femoral neck must be predetermined
and marked with a Kirschner wire.
The correct entry point for the 130 o plate is approximately 3 em
distal to the rough line of the greater trochanter. When inserted,
the plate should be in the centre of the femoral neck and about
6-8 mm above the calcar. The tip of the plate will then be at the
-=
3c
intersection of the tension and compression trabeculae, where
the plate has the best purchase. "'
The 130 o plate is available with 4, 6, 9 and 12 DCP holes, the last
--=
~
with a notch for the tension device. The indentation at the junc- E
2
tion between blade and shaft is for impaction of the plate. "'
Different blade lengths also are available: 50, 60, 70, 80, 90, 100, "CC
and 110 mm. =
-
~
"'
~
s:
~
- Thickness: 5.6mm ~
"CC
- Width: 16 mm
=
~
"CC
- U profile blade: 6.5- 16 mm ~
"EiJ
<=
157 •
Angled Blade Plates, 130 °, T Profile
The angled blade plates are used in small adults for fixation of
fracture of femoral neck and pertrochanteric fractures.
The T profile of the blade and the slightly smaller shaft fits the
small bone better. The insertion is similar to that of the large an-
gled blade plate, 130°. The seating chisel must have the same T
profile as the blade .The inserter- extractor for the large angle
blade plates can be used.
They are available with 4, 6 and 9 holes and with blade lengths of
50, 60, 70, and 80 mm.
- Thickness: 5.3mm
- Width: 14 mm
- T profile blade : 5-14 mm
Osteotomy Plates for Adults, U Profile

The osteotomy plates for adults are available with different an-
gles between blade and shaft. Standard plates have angles of
90 °, 100 °, 110 °, 120 ° and 130 °, but any other desired angle can
be obtained on special request. See SYNTHES catalogue.
The 90 o and 100 o plates have an offset to accommodate the
greater trochanter in intertrochanteric osteotomies. Depending
on the blade length (L), the depth of the offset (T) is either 10,
15, or 20 mm. The hole in the bend is for impaction of the plate
and for fixation of the calcar with a 4.5 mm cortex screw. The
blade lengths are 40, 50, and 60 mm.
The angled blade plates with an angle of 110 o or more are used
for repositioning osteotomies in pseudarthroses or nonunions
of the femoral neck. The blade length varies from 65 to 110 mm.
The shaft of all osteotomy plates has 4 DCP holes with a notch
for the tension device in the end holes.
Osteotomies are carefully planned and carried out only after all
anatomical landmarks and angles have been identified and
marked with Kirschner wires. The seating chisel and sometimes
the blade of the plate are inserted before the osteotomy is car-
ried out, using the same techniques and instruments as for the
(j regular angled blade plates.
·s.=5- Important dimensions :

1;,1 - Profile: See figure
~ - Thickness: 5.6 mm
"C
-Width: 16 mm
=
I:
= - Hole spacing : 16 mm
-=e
.i
0
- U profile blade: 6.5-16 mm
- Overall height : 94 mm
~
-
E
•
=
til
158
Osteotomy Plates for Small Adults and Adolescents,
90° T Profile
The osteotomy plates are used for intertrochanteric osteotomies
in small adults and adolescents, where the U profile would be too
wide and could cause breakage of the neck. The plates have an
offset (T) with a depth of either 10 or 15 mm to accommodate the
trochanter. The blade (L) with T profile is available in lengths of
40, 50, or 60 mm. For the preparation of the seat of the blade, a
seating chisel with the same T profile is needed.
The shafts of the plates have 3 DCP holes for 4.5 mm cortex
screws, the last with a notch for the tension device. The indenta-
tion in the offset is for impaction of the plate.
As in all procedures with angled blade plates, preplanning is es-
sential for the successful insertion of the implant. Anatomical
landmarks are identified and Kirschner wires inserted for orien-
tation. The seating chisel and sometimes the blade of the plate
are inserted before the osteotomy is carried out.
- Thickness: 4.5mm
- Width: 14 mm
- Tprofile blade: 5-11.7 mm
- Overall height: 78 mm
Osteotomy Plates for Children, T Profile

These plates conform to the small diameter of the femoral neck
of children up to 10 years and are used for derotation and varus
osteotomies. The plates are available with three different an-
gles: 80 °,90°, and 100°; two bladelengths35 and45 mm; and an
offset of 8 mm.
The shaft of the plates has 3 DCP holes for 4.5 mm cortex
screws. The small indentation in the offset is for careful im-
paction of the plate.
A seating chisel with corresponding T profile has to be used and
a special inserter- extractor.
The intervention is carefully planned and Kirschner wires
inserted as landmarks. The seating chisel and sometimes
the blade of the plate are inserted before the osteotomy is
carried out.
- Thickness : 3.5mm
- Width: 11.3 mm
- T profile blade: 4.5- 11.2 mm
- Overall height: 74 mm
159
•
Infant Hip Plates, 90° T Profile
These plates are used for derotation and varus osteotomies in
infants and in children up to 5 years. The plates are available in
two different blade lengths: 25 and 32 mm with offsets of 7 and
12 mm. The shaft has 3 DCP holes for 3.5 mm cortex screws.
A seating chisel with T profile of corresponding size is needed to
prepare the seat of the blade.
- Thickness: 2mm
- Width: 11 mm
- Hole spacing: lOmm
- T profile blade: 2-8mm
- Overall height: 46mm
Bifurcated Osteotomy Plate, 115°

The bifurcated plate is used for proximal femoral osteotomies
in small infants. The forked blade is designed to be inserted into
the medulla of the femoral neck. The shaft has 2 oval holes for
3.5 mm cortex screws. The blade lengths are 30 and 35 mm.
A special inserter- extractor is used for the insertion.
- Thickness: 1.1mm
- Width: 11 mm
II>
Cl.l
g. 6.8.3 Technique of Application
·a
.c
1.1
~ The application of the different angled blade plates both proxi-

"C
=
=
mally and distally requires great care and needs meticulous
=
=
planning. The fixed angle between the blade and the shaft does
-s
=
~
=
Cl.l
not allow for mistakes in the application.
The insertion techniques will be described in general terms in
the following.
..~= Depending on the fracture pattern, the techniques may have to

be modified .
• 160
6.8.3.1 Application of the Condylar Plate
in the Proximal Femur
Before starting the application in the proximal femur, the fol-

lowing has to be determined:
- The length of the blade
- The length of the plate shaft
- The entry point for the blade
- The position of the plate
This is best done by using a reversed X -ray to normal scale of the

contralateral side. It must be taken with the femur internally ro-
tated to obtain the true length of the femoral neck. The trans-
parent template of the condylar plate is placed on the reversed
film along the femoral shaft.The tip of the blade should lie in the
inferior half of the femoral head just below the intersection of
the tension and compression trabeculae where the blade has its
best purchase (see p.156). In the femoral neck the blade passes
about 10 mm below the superior cortex in the centre of the neck.
(See AO/ASIF preoperative planner).
The blade length can now be determined. The shaft length will
depend on the fracture pattern. The entry point in relation to
the rough line (innominate tubercule) of the greater trochanter
is noted.
Step by step procedure for the example of a subtrochanteric
femur fracture:
- Any wedge fragment is fixed with a 4.5 mm cortex screw as a
lag screw.
- A Kirschner wire, 2.0 mm in diameter, is placed below the an-
terior ridge which runs along the front of the intertrochanter-
ic area, onto the anterior surface of the femoral neck, and
driven into the head. It marks the plane of anteversion of the
neck (Fig. 1).
- Taking the predetermined entry point in the anterior half of
the greater trochanter into consideration, the condylar plate
guide is placed along the lateral cortex of the femoral shaft. A
second Kirschner wire is inserted (after pre-drilling with a
2.0 mm drill bit in dense bone) parallel to the upper edge of
the plate guide into the apex of the greater trochanter. It
should also be parallel to the anteversion Kirschner wire in
the coronal plane. This wire indicates the direction of the
blade of the plate (Fig.2).
- The first Kirschner wire can now be removed.
- The level of the entry in the anterior half of the lateral emi-
nence of the greater trochanter is marked with a chisel.
- The slot is prepared in the cortex with the 16 mm chisel, ap-
proximately 17 mm wide and 10 mm high.
161 •
- In dense bone it is necessary to drill for the channel with the
4.5 mm drill bit in the double drill sleeve end, 4.5 mm (Fig. 3).
The triple drill guide attached to the condylar plate guide can
also serve as a drill guide. The slot is formed with the router
(Fig.4).
- The distal rim is bevelled to receive the shoulder of the plate
(Fig.5).
- The chisel guide is set at an 85 o angle (using the plate itself 5
or the condylar plate guide) and mounted on the seating
chisel (Fig. 6).
- The seating chisel is hammered into the bone parallel to the
Kirschner wire in both planes. The slotted hammer is used
to control rotation about its long axis.The flap of the chisel
guide should lie in line with the long axis of the femur through-
out the insertion. The chisel is inserted to the predetermined
depth (Fig. 7).
Note: The chisel should not be driven forcefully, since this may
shatter the bone. Removing the chisel and drilling with the
4.5 mm drill bit may be necessary.
- The chisel is hammered back out with the slotted hammer.
- Insertion of the condylar plate: The plate is fixed in the insert-
er - extractor with its handle on a horizontal line with the '• 6
3 7
"'
=
~
c::r
-
'2
-=
~
~
-=eo:
=
--==
·=eo:
e
~
--=
"'
=
... 4 8
• 162
blade.The bolt is tightened with the open end wrench. It is
pushed into the pre-cut channel and inserted with light ham-
mer blows (Fig. 8).
- The inserter - extractor is removed and the impactor used to
seat the plate against the lateral cortex (Fig. 9).
- To triangulate the fixation, a 4.5 mm cortex screw is inserted
through the first plate hole into the calcar.
- With the 3.2 mm drill bit and the double drill sleeve end,
3.2 mm, the thread hole is drilled (Fig. lO).
- The length is determined with the large depth gauge (Fig.ll).
- Tapping with the 4.5 mm tap and sleeve (Fig.12).
9 - Insertion of the 4.5 mm cortex screw (Fig. 13). (In in-
tertrochanteric fractures it is inserted as a lag screw.)
- If suitable, a second screw is inserted through the next hole in
similar manner.
- If necessary, axial compression is achieved with the articu-
lated tension device: the opened device is hooked into the
last plate hole and a thread hole drilled through its footplate
using the 3.2 mm drill bit in the double drill sleeve end,
3.2 mm. Tapping for 4.5 mm cortex screw and insertion of a
short screw (Fig.14).
10
13
-e=
"'
--==
~
...
"'
=
"CC
-
~
"'
~
s:
~
I
~
"CC
=
~
"CC
~
"6il
<=
12
163
•
- The bolt of the device is tightened with the open end wrench
until the desired compression is obtained (Fig.15).
- The remaining 4.5 mm cortex screws are inserted in the plate.
Any screw crossing the fracture is inserted as a lag screw
(Fig. 16). The rest are inserted after drilling 3.2 mm, measur-
ing, and tapping as described above (Fig.17).
- The articulated tension device is removed and the last plate
hole fixed with a cortex screw (Fig.18 a, b).
15
17 18a 18b
16
6.8.3.2 Application of the Condylar Plate in the Distal Femur
Before the condylar plate can be inserted in the distal femur, the
following has to be determined through careful preoperative
planning:
- The plate length
- The point of entry
AP and lateral X-rays of the normal side are taken and used
reversed to plan the different steps of application. (See the
"' AO/ ASIF preoperative planner.)
·2'=
~
Anatomical features to consider:

'5 - When the distal femur is viewed laterally, the anterior part of
~ the condyle is the continuation of the femoral shaft. There-
-=; fore, the point of entry must be in the middle of the anterior
= half of the condylar mass so as to have the plate lined up with
-e5
.~
-; the femoral shaft. The entry point is in the extension of the
long axis about 1.5 em to 2 em above the knee joint. The slot is
made at this distance parallel to an imaginary line marking
E
-;; the longest diameter of the elliptically shaped lateral femoral
.S condyle .
• 164
- When viewed from below the femur has a trapezoidal shape.
The lateral side of the anterior part has an inclination of ap-
proximately 10 °, the medial side of approximately 25 °. The
\ length of the blade (B1) must therefore be shorter than the
AP (A) view suggests. The anterior surface is inclined to-
wards the medial side. This corresponds to the inclination of
I I the patellofemoral joint. The blade must be inserted with the
t
I
~I same inclination.
- In the horizontal plane the blade should be parallel to the
I I knee joint and about 1.5-2 em from the distal end.
I I
J ~ Step by step procedure for the example of a Y fracture :
- Fixation of the condylar fragments with two 6.5 mm cancel-
~.,
lous bone screws as lag screws avoiding the planned insertion
site of the blade (p. 81).
- T he knee is bent 90 o and the knee joint axis marked with a
t
p
-A--.
! first Kirschner wire (1 ).
- The second Kirschner wire (2) is inserted anteriorly over the
patellofemoral surface of the condyles to mark the inclina-
tion.
- The entry slot for the plate is marked and a third Kirschner
wire inserted distal to the slot. This third wire (3) must be par-
allel to the first wire (1) in the AP view and to the second wire
(2) in the axial view. Wires 1 and 2 can be removed. The third
wire is the definitive guide for the direction of insertion of the
seating chisel. The position can be checked with the condylar
plate guide (Fig.1).
- The entry slot is prepared with a 16 mm chisel: approx.
17 mm wide, 10 mm high and 10 mm deep. In hard juvenile
bone the channel has to be pre-drilled with the 4.5 mm drill
bit in the double drill sleeve end, 4.5 mm (Fig. 2). The proxi-
mal rim is bevelled with the chisel (Fig. 3).
-=e
"'
-..==
~
...
"'
"CC
=
-
C':l
"'
~
C':l
=::
~
"CC
=
C':l
2 3
"CC
~
'"S'Jl
<=
165
•
- The chisel guide is set at 85 o (using the plate itself or the
condylar plate guide) and mounted on the seating chisel
(Fig.4).
- The seating chisel is hammered in parallel to the definitive
Kirschner wire in both planes. The flap of the chisel guide
must be in line with the femoral shaft axis. The rotation is con-
trolled with the slotted hammer (Fig. 5).
- After reaching the desired depth the chisel guide is taken off
and the seating chisel removed with the slotted hammer.
- The selected plate is fixed in the inserter - extractor with the
blade on a horizontal line with the handle.The bolt is tight-
7
ened with the open end wrench.
- The plate is pushed into the prepared channel and inserted
with light hammer blows. Rotation about its axis is controlled
with the slotted hammer (Fig. 6).
- After removal of the inserter- extractor, final seating of the
plate using the impactor (Fig. 7).
- The plate is fixed to the distal fragment with two 6.5 mm can-
cellous bone screws. In Y fractures these screws should be in-
serted as lag screws.
- The 3.2 mm drill bit in the double drill sleeve end, 3.2 mm, is
used to drill through the round plate hole nearest the blade
(Fig. 8). In hard juvenile bone the near cortex may have to be
drilled with the 4.5 mm drill bit to accept the screwshaft with-
8
out cracking.
- The hole is tapped using the 6.5 mm tap and the double drill
sleeve end, 6.5 mm (Fig. 10).
L 4 9
"'
=
~
·a.cC"
c.J
~
-==
eo r--:
--=
=
.~
eo
5
..-=e
~
...."=' 6 10
• 166
- The appropriate 6.5 mm cancellous bone screw is inserted
(Fig.ll).
- These steps are repeated in the second round plate hole.
- If axial compression is desired the articulated tension device
is used: The opened device is hooked into the last plate hole
and fixed to the bone with a short cortex screw. By tightening
the the bolt of the device the necessary compression can be
obtained (Fig. 12).
- Fixation of the plate by inserting 4.5 mm cortex screws one by
one: Drill bit 3.2 mm and the DCP drill guide 4.5 mm are used
to drill the thread hole (Fig. 13). Measuring, tapping and in-
11 sertion of the screws (Fig. 14).
- Removal of the articulated tension device.
- Insertion of the remaining 4.5 mm cortex screws (Fig.15 a, b).
15a 15 b
6.8.3.3 Application ofthe 130° Angled Blade Plate

in the Proximal Femur
The use of the 130 o angled blade plate has decreased since the
DHS was introduced, but is still used in intertrochanteric frac-
tures, especially if the DHS system is not available.
Preoperative planning is necessary to obtain the following im-
portant information:
- The point of entry
- The length of the plate
An X-ray of the uninjured side is used in reverse for the plan-
ning. This is taken with the femur internally rotated 15 o- 20 o to
obtain the true length of the femoral neck. Using the transpar-
ent template of the 130 ° plate (see the AO/ASIF preoperative
planner), the position of the plate is determined. The tip of the
blade should lie in the centre of the femoral neck just below the
167
•
intersection of the tension and compression trabeculae about
8-10 mm above the calcar (see p.157). This is where the plate
has the best purchase. The length ofthe blade is noted.
With the shaft lined up against the femur the entry point can be
determined. It is approx. 3 em distal to the rough line (innomi-
nate tubercle) of the greater trochanter.
The fracture pattern determines the length of the plate and the
steps of insertion. Four or six hole plates are most commonly
used.
Step by step procedure for the example of a subcapital fracture:
- After reduction the first Kirschner wire is inserted to deter-
mine the anteversion of the femoral neck axis. It is placed be-
low the anterior ridge running along the front of the in-
tertrochanteric area and driven into the head (Fig.1 ).
- Variation : using the triple drill guide with the attached side
guide, a 3.2 mm drill bit or a 3.0 mm Kirschner wire is inserted
instead of the first Kirschner wire in the same position about
8-10 mm above the calcar.
- A second Kirschner wire is driven into the greater trochanter
(pre-drilling with 2.0 mm drill bit in dense bone) parallel to
the first wire in the coronal plane and parallel to the upper
edge of the 50 o triangular positioning plate placed on the fe-
mur along the lateral cortex (Fig. 2). This wire indicates the
direction of plate insertion. The first wire is removed.
- The triple drill guide placed on the lateral cortex can be used
for the preparation of the slot. This should be midway between
the anterior and posterior surfaces of the femoral shaft. A
4.5 mmdrill bit is used to drill for the channel (Fig.3). Leaving
this drill bit in place, a second 4.5 mm drill bit is used to drill the
two remaining holes. Removal of the triple drill guide and
drills.
- The router mounted in the small air drill is used to combine
the three holes into a slot (Fig. 4).
- The distal rim is bevelled with a 16 mm chisel to avoid shatter-
ing of the cortex (Fig. 5).
"'
=
~
="'
·a
.c:
~"'
-=
=
~
....=
.~
....
~
e=
~
....=
...
...
"'= 2
• 168
- The chisel guide is set at 50 o using the plate itself or the trian-
gular plate guide. It is mounted on the seating chisel.
- The seating chisel is inserted parallel to the Kirschner wire in
both planes. The flap of the chisel guide must remain in line
with the long axis of the femur. The slotted hammer is used to
maintain and, if necessary, to correct the rotational alignment
of the seating chisel (Fig. 6).
- When the desired insertion depth is reached, the chisel guide
is removed and the slotted hammer used to remove the seat-
ing chisel.
- The selected plate is tightened in the inserter - extractor as
close to the shoulder as possible. The handle must be on a
horizontal line with the blade (Fig. 7).
- The plate is pushed into the prepared channel by hand and
then inserted with light hammer blows. Removal of the in-
serter - extractor.
- The impactor is used to finally seat the plate. If correctly
planned, the plate should be aligned with the femoral shaft
(Fig.8).
- Fixation of the plate with 4.5 mm cortex screws. Drill bit,
3.2 mm, in the DCP drill guide, 4.5 mm (Fig. 9).
- The length is measured (Fig.lO).
-e=
"'
---==..=
~
"'
=
-
e'l:l
nr.n:n ... . . ,. "'
~
e'l:l
~
-=
~
=
e'l:l
-=
~
"5i:J
10 -<=
169
•
- Tapping with the 4.5 mm tap in the double drill sleeve end,
4.5 mm (Fig.ll).
- Insertion of the 4.5 mm cortex screw (Fig.l2).
- The remaining screws are inserted using the same technique
(Fig.13).
- Removal of the Kirschner wire. Final tightening of the screws
(Fig.l4 a, b).
11
13 14b
12 14a
6.8.3.4 Application of the Osteotomy Plates
Intertrochanteric osteotomies are performed to correct a varus,

valgus, extension, flexion, or rotational deformity of the
femoral neck (or combination deformities). Repositioning os-
teotomies are occasionally indicated for fresh fractures of the
femoral neck, but most frequently for subcapital pseudarthrosis
with a viable head.
Owing to the fixed angle of the AO/ASIF angled blade plates, it
is possible to perform highly accurate osteotomies by carefully
fl.)
planning the procedure in advance.
Prior to surgery it it necessary to quantify all the components of
·a
~
deformity and calculate the necessary angles of correction. The
"5 basis of these calculations is the preoperative drawing made
~ from radiographs of the unaffected side. (See AO/ASIF preop-
=
"'C
erative planner.)
~
= As in the fixation of fractures it is necessary to identify the fol-
-
.£ lowing before the insertion of the osteotomy plate:
-;
5 - The point of insertion
5 - The direction of blade insertion
tl= - The displacement angles
.5 - The type of osteotomy plate
• 170
Step by step procedure for the example of a varus inter-
trochanteric osteotomy:
- A first Kirschner wire (1) is inserted along the front of the
femoral neck into the femoral head to indicate the antever-
sion of the neck.
- A second Kirschner wire (2) is inserted into the greater
trochanter parallel to the upper edge of the triangular guide
plate (e. g. 60 °). This wire is also parallel to the front of the
2 femoral neck axis as marked by the first wire and establishes
the blade direction (Fig.1).
- The first wire can be removed.
- About 5 mm distal to the site of the planned osteotomy, a
3 2.0 mm hole is drilled perpendicular to the femoral shaft axis,
and a third Kirschner wire (Fig. 2) is inserted at the same
anteversion angle as the second Kirschner wire.
- In derotation osteotomies, two additional Kirschner wires
may be inserted to mark the necessary angles of correction.
- About 20 mm above the site of the planned osteotomy, and in
the anterior half of the greater trochanter aligned with the
long axis of the femur, the entry slot for the blade is prepared
with a chisel.
4 - The seating chisel is inserted approx. 40-50 mm with the ham-
mer in the same direction as the second Kirschner wire indi-
cates. The flap of the chisel guide is in line with femoral shaft;
the rotation controlled with the slotted hammer (Fig. 3).
- The chisel is then withdrawn 10-20 mm to facilitate later
5 removal.
- The osteotomy is performed with the oscillating bone saw at
the planned site (Fig. 4).
- Using the seating chisel as a handle, the proximal fragment is
tipped into varus.
- Starting from the middle of the osteotomy, another cut is
made into the proximal fragment parallel to the seating chis-
el.The 30 ° excised wedge is removed (Fig. 5).
- The seating chisel is extracted with the slotted hammer. Care
6 must be taken not to dislocate the proximal fragment. A sec-
ond slotted hammer is useful to hold the fragment.
- The selected osteotomy plate is fixed in the inserter- extrac-
tor at the shoulder. The blade and the handle are on one line.
- The plate is pushed into the pre-cut channel by hand (Fig. 6).
It is further inserted with light hammer blows and, finally,
after removal of the inserter-extractor, with the impactor.
- The plate is held against the shaft with a reduction forceps.
- The tension device is hooked into the last plate hole and fixed
with a short cortex screw. Tightening the screw will produce
the desired compression (Fig. 7).
- The plate is fixed with 4.5 mm cortex screws: drill bit, 3.2 mm,
and DCP drill guide, 4.5 mm, large depth gauge, tap for
4.5 mm cortex screw, and insertion of the screw.
8 - The tension device is removed and the last screw inserted
(Fig.8).
171 •
6.8.4 AO/ASIF Instruments for Application
and Removal of Angled Blade Plates
Instruments for the application of condylar plates in adults
"'
=
QJ
a'
·=
'5
~
"C
=
--
.s=
~
=
e
QJ
...-=
2
"'
• 172
Instruments for the application of 130 o angled blade plates in
adults
II
Instruments for the application of osteotomy plates in adults
:.!1
-e=
"'
-==
~
...
;:l ....."'
"CC
=
-
C'il
"'
~
C'il
6::
~
"CC
=
C'il
"CC
~
"5il
<)II
= ~=
173
•
Instruments for the application of condylar plates in small
adults and adolescents
lI
,.
Instruments for the application of 130 o angled blade plates in

small adults
"'
~
·a.c=
cr
(j
~
=
"C
~
§
·g... •
=
e
~
-
.s
...=
< ll
• 174
Instruments for the application of osteotomy plates in small
adults, adolecents and children
I
,I
;
=
Instruments for the application of osteotomy plates in infants
175 •
Instruments for the removal of angled blade plates in adults
Instruments for the removal of angled blade plates and osteo-

tomy plates in small adults, adolescents and children
Instruments for the removal of osteotomy plates in infants
,.,
~
&
·a..c:
~
~
"C
;
-
·=~=
=
Procedure
~
S After removal of the screws, the appropriate inserter - extrac-
~ tor is fixed at the shoulder of the plate, the handle in line with
.S the blade. The slotted hammer is used to hammer out the plate.
• 176
6.9 Small Fragment Instruments and Implants
6.9.1 Small Fragment Instruments
The instruments used for reduction, temporary fixation of small

fragments , and insertion of small fragment implants, are similar
in principle to those used for large fragments, but of dimensions
that correspond to the bone size. The general characteristics of
instruments described in Sect. 6.3.1 apply also to those men-
tioned below. In this section the specific use of each instrument
will be discussed.
Small fragment instruments and implants can be obtained in
either a graphic case or in a sterilising tray
On drill bit and tap design, see Sect. 6.2
...,00.::!!-~----iiiiiiiiiM_iiiii.._iii&(~
s [J.[!' Drill Bit, 2.5 mm Diameter
-=
This bit, 110 mm/85 mm (total and effective lengths), two-flut-
ed, is used to prepare the thread hole for the 3.5 mm cortex [IJ
screw and the 4.0 mm cancellous bone screws. It is gold/brown- ~
-=e
"S.
coloured for easy identification. To simplify the insertion tech-
nique, it is now the drill bit of choice for all small fragment
-=
"'CC
screws. The quick coupling end fits the small air drill. The drill ~
[IJ
bit should always be used with a drill guide or sleeve of corre-

e
Q.j
--=e
sponding size.
-i=
[ IJ
0 5 Drill Bit, 3.5 mm Diameter

This bit, 110 mm/85 mm (total and effective lengths), is used for Q.j
the gliding or clearance hole when the 3.5 mm cortex screw is in-
serted as a lag screw. It has a quick coupling end to fit the small ~
air drill. A drill sleeve of the same size should be used to protect
the soft tissue.
177
•
Small Countersink, 3.5 mm/4.0 mm
This is used to cut a recess in thick cortex to accommodate the
screw head and to distribute its pressure evenly. It is used when
small fragment screws are inserted as single screws. The 2.0 mm
diameter tip centres the countersink in the pre-drilled thread
hole. It is used with the T handle, never with power.
Countersinks manufactured now have five cutting edges in-
stead of four. This increases the cutting capability and reduces
the rattling.
Depth Gauge, 3.5 mm- 4.0 mm

This gauge measures the drilled depth for small fragment screws
up to 60 mm. The hook has to engage the opposite cortex se-
curely before the sleeve is pushed onto the bone, or plate, and
the measurement read. If the drill hole is at an angle the longest
diameter must be measured.
Depth gauges of recent design have a locking screw to avoid in-
terchanging the sleeve with that of a different sized depth gauge.
The old-style depth gauge measuring up to 50 mm may still be
used.
Note: Always measure before tapping.
Tap for 3.5 mm Cortex Screws

This tap is gold/brown-coloured and is used to pre-cut the
thread in the bone before the cortex screw can be inserted. The
50 mm long thread has the same 1.25 mm pitch as the screw
thread, but only the first two conically increasing threads are
cutting. Bone debris is deposited in the flutes, which now extend
from the tip through the first ten threads. The long thread pro-
tects the already cut thread as the tap is advanced. Using the T
handle, it is turned clockwise twice and anticlockwise once to
clear the thread of bone debris. It is not recommended to tap
with a machine, since the tap advances with too high a speed,
and the sensation of completion of tapping the far cortex is lost.
This may result in overpenetration and damage to the soft tissue
on the far side of the bone. The tap should always be used with a
protecting sleeve.
"'
·a=
~

.c
<:.1
This tap has been redesigned for easier identification. It now re-
~
't:l sembles the large 6.5 mm tap with short thread and a shaft. The
=
~ short threaded part with 1.75 mm pitch is long enough to cut the
=
0 near cortex before inserting a 4.0 mm cancellous bone screw. If
3= tapping the opposite cortex is necessary, care must be taken not
to destroy the already tapped bone. The rather narrow shaft of
-e
e
~
the tap makes this easier. It is used with the T handle and a pro-
tecting sleeve.
....~
• 178
The previous, long threaded tap for 4.0 mm screws may still be
used.
THandle
This handle with quick coupling is used with the countersink
and the taps. With this handle more force can be exerted when
tapping hard bone than with a straight handle.
Triple Wire Guide, 2.0 mm

This wire guide can be used as a guide when Kirschner wires are
inserted. The three holes on one side allow parallel placement
of wires, especially in the tension band wiring technique.

This piece has a sleeve at each side of a handle. One sleeve has
an inside diameter of 3.5 mm to accept the 3.5 mm drill bit and
tap. The sleeve on the other end has an inside diameter of
2.5 mm and an outside diameter of 3.5 mm. This is used with the
2.5 mm drill bit. It can also be used as an insert sleeve in a
3.5 mm gliding hole to guide the 2.5 mm drill bit into the oppo-
site cortex in the lag screw technique. The serrated end of the
double drill sleeve permits a secure hold on the bone surface
while drilling. The holes in the handle near the sleeve can be
used for Kirschner wires up to 1.6 mm diameter when a parallel
screw is to be inserted. The distance of 4.5 mm between
Kirschner wire and the screw permits use of a washer if neces-
sary.
Insert Drill Sleeve, 3.5 mm/2.5 mm

This sleeve is used in lag screw technique if the 30 mm long dou-
ble drill sleeve is too short. The insert sleeve is pushed into the
pre-drilled gliding hole and the 2.5 mm drill bit used to drill the
thread hole in the far cortex.

This has a neutral (green) and a load (yellow) guide. The end of
each guide fits precisely in the 3.5 mm DCP plate hole and per-
mits pre-drilling for a neutral or a load screw with the 2.5 mm
drill bit. The drill hole for the load screw is prepared by placing
the guide with the arrow pointing towards the fracture; 1 mm
displacement is then achieved. The handle can be rotated into
the desired position and is removed for cleaning.
The measurement 3.5 mm refers to the screw size of the screws
used with this plate.
Note: The DCP drill guide should only be used with D CP plates.
179 •
LC-DCP Drill Guide, 3.5 mm
This is the drill guide used with LC-DCP, 3.5 mm. It is similar to
the DCP drill guide, in that it has a neutral (green) and a load
(yellow) guide, combined on one handle. The inserts will only fit
this special handle. It has been designed with the same under-
cuts as the plate. This allows it to be easily distinguished from
the DCP drill guide handle.
The handle is marked with the different positions of the guides.
The neutral guide places the screw in a neutral position, if the
arrow points towards the fracture. Turned 180°, with the arrow
away from the fracture, a buttress position is obtained. The load
guide places the screw in an eccentric position for compression
when the arrow points towards the fracture.
The displacement is 0.75 mm. Because of the hemispherical end
of the guides, they have a congruent fit in the plate hole , also
when tilted 40 o in the longitudinal, and ±7 o in the transverse
plane.
Note: The LC-DCP drill guide should only be used with LC-
DCPplates.
LC-DCP Universal Drill Guide, 3.5 mm

This is as the name indicates a guide for universal use. It is simi-
lar in design and function to the LC/DCP drill guide, 4.5 mm. It
has two sleeves combined on one handle. One sleeve has an in-
ner diameter of 3.5 mm and is used with the 3.5 mm drill bit and
the tap for 3.5 mm cortex screws. The other end consists of two
components: an outer sleeve, which has an end that corresponds
exactly to the hemispherical undersurface of the screw head,
and an inner sleeve with serrated end. This sleeve accepts the
2.5 mm drill bit. The two sleeves are pre-loaded by a spring in
such a way, that the inner sleeve protrudes at the tip. By apply-
ing pressure the inner sleeve is pushed back into the outer
sleeve. When the guide is placed in the plate hole and pressure is
applied, the outer end of the sleeve follows the inclined "cylin-
der" to a neutral position. Here no compression is exerted, and
a hole for a neutral screw can be drilled. The load position for a
screw is obtained by placing the inner protruding sleeve at the
end of the plate hole (far from the fracture). Similarly, the but-
tress position is obtained when the sleeve is placed at the end of
the plate hole nearest the fracture. (See also pp. 88 and 89).
Because of the round end of the guide, which corresponds to the
hemispherical undersurface of the screw head, an exact fit be-
tween the plate hole and the screw head can be established. This
is important because no undesirable torque between bone seg-
ments will then occur. It is also possible to place a screw at an an-
gle and still maintain the congruent fit.
The degree of inclination is limited to values that provide an
exact fit.
• 180
Small Hexagonal Screwdriver
This screwdriver has a hexagonal tip (width across flats 2.5 mm)
which fits snugly in the hexagonal head socket of the small frag-
ment screws, allowing easy insertion and removal. The shaft has
a groove which is necessary to connect the screw-holding sleeve.
The handle is designed so that excessive force cannot be applied
when inserting the screws. The old-style screwdriver with sim-
ple holding sleeve may still be used.
Note : Never use a screwdriver with a damaged tip. This will then
damage the screw head socket and make removal difficult.
Small Screw-Holding Sleeve

This sleeve holds the screw by a self-retaining mechanism. It is
slid onto the screwdriver shaft which has a groove to locate it. It
is especially useful when removing shaft screws since traction
can be applied. The screw-holding sleeve has to be disassem-
bled carefully for cleaning.

This shaft can be connected to the small air machine for inser-
tion of long screws. This has to be done with great care to avoid
stripping of the bone. The shaft may also be connected with the
T handle, and used as a reserve screwdriver. It cannot be used
with the small screw-holding sleeve, only with the simple sleeve
(see p.186).
Sharp Hook
This hook is used to inspect fracture lines, and to reduce frag-
ments. It can also be used to clean screw head sockets before re-
moval, and to clear threads of bone and tissue debris.
-=
Holding Clip, 3.5 mm
This clip is made of implant material and can be used to hold "'
c.
e'il
plates and washers. Regular safety pins cannot be used because
of the risk of corrosion being transmitted. ...e
-e=
"C
;
Screw Forceps "'
Q,j
-...=..=
This forceps with a simple self-holding mechanism is used to
remove screws from the rack.
"'
=
e
Q,j
=tl
181 •
Bending Templates, 87 mm and 114 mm
These templates are made of anodised aluminium. They are
placed on the bone to determine the shape and position neces-
sary for a plate. They then serve as models when carefully con-
touring the plates. One side is marked with the hole configura-
tion of a DCP, the other side with that of a LC-DCP. For
cleaning, see Sect. 6.22.4.2.
Bending Irons for Small Plates, 2. 7 mm and 3.5 mm, 150 mm

LC-DCP/DCP
These irons have two slots with different widths to accommo-
&~.$S3Z!P.t&
date small fragment plates of various thicknesses. Bending and

twisting is performed by placing the two irons opposite each LC- DCPIDCP
other. The differently orientated slots allow easy overbending
O~ISS:st'9~
of the plate middle. The longitudinal slot at the ends can also be
used for twisting and bending.
Wire Bending Pliers

These pliers can be used to hold and bend wires (see Sect.
6.17.3). They can also be used to cut wires up to 1.6 mm diame-
ters on the side.
Bending Iron for Kirschner Wires

This iron is used to bend Kirschner wires close to the bone or
skin. In tension band wiring technique the iron and a hammer
are used to drive the hooked end into the bone. See Sect. 6.17.3
• 182
Reduction Forceps with Points, Narrow, 132 mm
This forceps has narrow serrated jaws and points. It can be used
to reduce even markedly displaced fragments without causing
soft tissue trauma. The main application is in the forearm, clavi-
cle, ankle, metacarpus, and metatarsus. The fine ratchet lock
makes handling easy and precise.
Reduction Forceps with Points, Broad, 132 mm

This forceps has broad, serrated jaws and points. It is used on
the same bones and in similar manner as the one mentioned
above, but allows space for a plate. It also has a fine ratchet lock.
Reduction Forceps with Serrated Jaws, 140 mm

This forceps is excellent for reduction and temporary retention
of a plate, e. g. on the forearm or the fibula. The ratchet is easy to
handle and to close. The forceps also is available with a speed
lock
Self-Centering Bone Holding Forceps, 190 mm

This forceps ("Verbrugge") has a sliding joint which permits
-=
"'
~
"S.
modification of reduction and plate holding ability. The speed ....e
-=
"C
lock allows rapid closure. By squeezing the handles slightly, the ~
locking nut can be unscrewed easily. "'

=
e
Q,l
-=
...
-
....=
"'
=
e
Q,l
183 •
Small Retractor, Width 8 mm, 160 mm
This retractor is used to expose the fracture without applying
pressure on the wound edges. The small size makes it useful, es-
pecially for metacarpal and metatarsal bones.
Retractor for Small Fragments, Width 15 mm, 160 mm

This retractor has a wider blade and is therefore suitable for ex-
posure of fractures of the forearm bones or of the fibula.
Periosteal Elevator, Round Edge, Width 6 mm

This elevator has a slightly curved blade and is used to expose the
fracture edges, without widely stripping the periosteum. It is also
used to clean the fracture of debris and to reduce fragments.
Drill Bit, 2.0 mm

This bit was used formerly to drill the thread hole for small can-
cellous bone screws. Their core size of 1.9 mm would allow this
size of thread hole. However, in dense cortical bone, the 2.3 mm
shaft of the screw could crack the bone. (Additionally, oblique
drilling with the drill bit 2.0 mm occasionally would result in col-
lision with the endosteal surface of the far cortex at such angle
that it skidded. Continued rotation of the drill bit, as it bent,
then risked breakage.) Today, therefore, it is recommended that
the 2.5 mm drill bit be used instead. The 2.0 mm bit is used to
pre-drill for Kirschner and cerclage wires.
Drill Bits, 2.5 mm and 3.5 mm

These bits are available in other lengths, also two- or three-flut-
ed, or with a triangular end to fit the Jacobs chuck. See the SYN-
THE S catalogue for details.
Tap f or 3.5 mm Cortex S crew

This tap is available with a 110 mm long thread for screws longer
than 50 mm (as used in pelvic surgery) See Sect. 6.10.1. It is im-
portant to use a tap with a thread as long as the screw thread or
the pre-cut thread in the bone will be damaged.
Depth Gauge, 3.5 mm - 4.0 mm

This depth gauge is used for measuring small fragment screws
up to 110 mm for example in pelvic surgery. The design and
function is the same as the shorter depth gauge.
• 184
Small Hexagonal Allen Key
This key can be used as a reserve for removing screws with a
2.5 mm hexagonal socket, e. g. 2. 7 , 3.5 and 4.0 mm screws.
Reduction Forceps with Points, 130 mm

These "towel clip" style forceps are available with speed lock or
ratchet closure.
Bending Pliers
These pliers with adjustable anvils for small fragment plates en-
sures precise bending and requires little force. The large bend-
ing pliers for large plates has an anvil suitable also for the small
fragment plates.
Bending Templates for Reconstruction Plates, 3.5 mm,

Straight and Curved
These templates are moulded onto the bone to be used as a
model when the plates are contoured. They are made of
anodised aluminium and need special care when cleaned. (See
Sects. 6.10.1 and 6.22.4.2.)
Bending Irons for Reconstruction Plates, 2. 7 mm- 3.5 mm

There irons are used in pairs for bending and twisting. By plac-
ing the plate onto the special pegs bending "on the flat" can be
performed. Twisting can be achieved using the slots in the ends.
Bending Pliers for Reconstruction Plates 2. 7 mm - 3.5 mm

These pliers are designed to allow for three-dimensional bend-
ing without exceeding the permitted 15 oat any one site.
185 •
Small Distractor
The small distractor can be used for distraction and reduction of
fractures in small bones. The pin holders that are mounted on
the carriage have two holes. In one hole, the 2.5 mm threaded
Kirschner wire is inserted and fixed with a screw. The second
hole may be used for a parallel Kirschner wire or screw to pre-
vent rotation of fragments. The connected wires or screws are at
right angles to the spindle, and no corrections can be made with
the pin-holders. The Kirschner wires must therefore be parallel,
and inserted at right angles to the long axis of the bone. Excur-
sions of 10 mm- 40 mm are possible. Seep. 357.
Bone Spreader, 140 mm

The bone spreader for small fragments, is sometimes needed to
remove soft tissue trapped between fragments or to inspect the
fracture surface.

This tap with 60 mm thread has been replaced with the new
short-threaded tap.
Small Pointed Drill Guide

This drill guide used for reversed lag screw technique has been
discontinued, since the technique is rarely indicated.
Tap Sleeve 3.5 mm/2.5 mm Drill Sleeve

This tap sleeve has been replaced by the double drill sleeve,
3.5 mm/2.5 mm.
Tap Sleeve, 3.5 mm

This tap sleeve has been replaced by double drill sleeve,
3.5 mm/2.5 mm.
DCP Drill Guide 3.5 mm

This drill guide for drill bit 2.0 mm is not to be used. The hole for
the 3.5 mm cortex screws should be pre-drilled with drill bit
2.5mm.
Depth Gauge
This depth gauge measuring up to 50 mm has been replaced by
the depth gauge with locking screw measuring up to 60 mm.
• 186
Small Hexagonal Screwdriver with Holding Sleeve
:c:=::=.;~',;
This piece has been replaced by the small hexagonal screw driv-
er with the new screw-holding sleeve.
Bending Templates
These bending templates for small plates without screw hole
markings are replaced by the DCP/LC-DCP templates.
6.9.2 Small Fragment Implants
Small fragment implants have been designed for fixation of

fractures in the forearm, the distal end of the humerus, the fibu-
la, the ankle, as well as small fragments of large bones. They are
also used in acetabular and pelvic fractures. The size and
strength of the implants correspond to these specific areas.
Therefore, they should not be used where for mechanical and
anatomical reasons other sizes are recommended. The evolu-
tion of the design and technique of application, as well as new
development, of current implants comes from experience and
continuous research. Most of the implants are available in both
stainless steel and in titanium. See SYNTHES catalogue.
In the following the present standard implants will be discussed,
and some earlier versions of implants merely mentioned in
Sect. 6.9.2.4.
6.9.2.1 Small Fragment Screws
Small fragment screws are used either as lag screws or as plate

fixation screws. The short and fully threaded cancellous bone
screws, 4.0 mm diameter are used in the metaphyseal/epiphy-
seal regions of small bones. The cortex screw and the shaft
screw, 3.5 mm diameter are mainly used in the diaphysis. The
screw head is the same size for all these screws and has a hexago- ..'!l
nal socket to accept the small hexagonal screwdriver. The small =
c.
~
cannulated screw is for special applications, and is discussed in

....e
Sect.6.6.3 -==
-
~
4.0 mm Cancellous Bone Screw, Partially Threaded "'

=
e
<Ol
This screw has a smooth shaft and is commonly used as a lag

-=
...
-=
screw in ankle fractures, as well as in fractures of the distal ra-
dius. The thread is designed to give good purchase in cancellous
...."='
bone. The thread length increases from 5 mm to 15 mm in pro-
e
<Ol
portion to the screw length. Screw lengths from 10 mm to ell
50 mm are available. ~
It is now recommended that the 2.5 mm diameter drill bit be
used to pre-drill for the screw, rather than the previously advo-
187
•
cated 2.0 mm drill bit. The 2.4 mm shaft of the screw would fit in
the hole without risk of cracking, especially in dense, juvenile
bone The 4.0 mm cancellous bone screws, partially threaded,
are available in lengths from 10 mm to 50 mm, in 2 mm incre-
ments up to 30 mm, and then in 5 mm increments to 50 mm.
2.5
Important dimensions: j
- Head diameter: 6.0 mm css;;s
- Core diameter: 1.9 mm (titanium2.0 mm) l
4f)
- Pitch: 1.75 mm
- Drill bit for thread hole: 2.5 mm
- Tap for 4.0 mm cancellous bone screws.
4.0 mm Cancellous Bone Screws, Fully Threaded

These screws are used mainly for the fixation of thin small frag-
ment plates to the metaphysis and are not to be used as a lag
screws. The thread profile is the same as that of the partially
threaded cancellous bone screw. Its predecessor, the 3.5 mm
screw, with 1.75 mm pitch, is discussed in Sect. 6.9.3.
4.0 mm cancellous bone screws, fully threaded, are available in
lengths from 10 mm to 60 mm, in 2 mm increments up to 30 mm,
and then in 5 mm increments up to 60 mm.
- Core diameter: 1.9 mm (titanium2.0 mm)
- Pitch: 1.75 mm
- Drill bit for thread hole: 2.5 mm
- Tap for 4.0 mm cancellous bone screws.
3.5 mm Cortex Screw

Since its introduction in 1983, this is the screw which should be
used as a lag screw or for plate fixation in the diaphysis of small
EfjEtJ
bones. Its holding power in dense cortical bone has increased
because of the 1.25 mm pitch and the asymmetrical buttress
threads. The core diameter of 2.4 mm increases the torsional
and bending strength of the screw, preventing shearing when it
is used as load screw in self-compression plates. It is not a self-
~.5 4.0 3.5
I I
tapping screw and the thread must be cut with the 3.5 mm tap
(coloured gold/brown) before insertion.
The 3.5 mm cortex screw is available in lengths from 10 mm to
110 mm, in 2 mm increments up to 40 mm, and then in 5 mm in-
crements up to 110 mm ..
• 188
2,5 Important dimensions:
1.25 2.5
@ - Thread diameter : 3.5 mm
3.5 2,4 60' - Pitch: 1.25 mm
- Drill bit for gliding hole : 3.5 mm
- Drill bit for thread hole : 2.5 mm
- Tap: 3.5 mm
3.5 mm Shaft Screw in Titanium

This screw has been introduced with the LC-DCP system for
use as load screw and lag screw. The shaft has the same diameter
as the thread, 3.5 mm.lt is much stronger than the threaded por-
tion in bending forces. Used as an inclined lag screw, it is 60%
more efficient than a fully threaded screw, since the smooth
shaft can not produce any undesirable grip in the gliding hole of
near fragment. The screw is not self-tapping; the thread must be
pre-cut with the 3.5 mm tap (gold/brown colour).
Lengths from 10 mm to 50 mm are available in 2 mm incre-
ments up to 40 mm, then in 5 mm increments.
2.5
I
c:s:s;:....... 1,25 2.5 - Head diameter: 6.0 mm
Giiiiii@iii @ - Shaft diameter: 3.5 mm
l
3.5 2.4 3.5 60' -
- Thread diameter : 3.5 mm
l 1.25 mm
css;::. - Pitch:
- Drill bit for gliding hole: 3.5 mm
- Drill bit for thread hole : 2.5 mm
-Tap : 3.5 mm
Washer, 7 mm
-=
This washer is available to be used with the 4.0 mm cancellous
bone screw to prevent the screw head from breaking the cortex "'
in the metaphysis. The flat side is placed on the bone; the coun-
c.
~
tersunk side accepts the hemispherical undersurface of the

screw head.
...s
-=
"C
~
"'
=
s
-
~
=
...="""'
-s
=
~
OJ)
189 •
Spiked Washer, 8.0 mm/3.2 mm Diameter
This washer made of polyacetate, and reinforced with stainless
steel for X-ray contrast, can be used for reattachment of avulsed
ligaments. A 4.0 mm cancellous bone screw is used for the fixa-
tion.
The polyacetate washer may be sterilised in temperatures up to
140 o C, (or 270 o F), allowing a minimum of 8 h for cooling and
rehardening. EtO (Ethylene oxide) sterilisation is also possible, '\-'\- - -
~- -
followed by a full cycle aeration.
6.9.2.2 Small Fragment Plates
One- Third Tubular Plates

These plates have the form of one-third of the circumference of
a cylinder. They have low rigidity since they are only 1 mm
thick. The plate is used mainly for the fixation of fractures in the
lateral malleolus, the distal ulna, the olecranon, and the
metatarsak The oval holes permit eccentric positioning of the
screws, which can be used for axial compression of a fracture. To
achieve this, the wide middle section of the plate is placed over
the fracture. The screws nearest the fracture in each fragment
are inserted eccentrically away from the fracture. The plate is
fixed with 3.5 mm cortex screws in diaphyseal bone, and 4.0 mm
cancellous bone screws in the metaphyses.
The plate offers good longitudinal stability if in complete con-
tact with the bone, either by the edges along the plate or by the
"collar" on the undersurface of each plate hole. The following
must be considered: Because of the "one-third of a tube" cross-
section, the screw head is almost flush with the plate surface
when inserted through the plate hole. As a consequence the un-
dersurface of the screw head protrudes through the undersur-
face of the plate. If used on a bone with a small circumference
the screw head may be in contact with the bone, blocking the
plate from being securely fixed. To overcome this problem some
plates (titanium plates at present) have a collar around the holes
on the underside. These collars prevent the screw head from
protruding and secure the plate/bone contact. The plates are
available in lengths from 25 mm to 145 mm, with 2 to 12 holes.
- Thickness: 1mm
- Width: 9mm
- Hole spacing: 12 mmand 16 mm
• 190
Dynamic Compression Plates, DCP, 3.5 mm
These plates are used with cortex screws 3.5 mm, hence the
name. It is the implant of choice for the fixation of fractures in
the forearm. It may also be used for distal humerus fractures
and the clavicle. The DCP hole design and working principle are
analogous to those of the DCP, 4.5 mm. See Sect.6.5.1.1
The holes allow for 1 mm displacement, if a load screw is used.
The 3.5 mm DCP drill guide must be used with this plate to en-
sure the load effect of the screw. The plate can also be used with
the articulated tension device. If necessary, 4.0 mm cancellous
bone screws can be inserted in the end holes.
The plates are available in lengths from 25 mm to 145 mm, with
2 to 12 holes.
- Thickness: 3.0mm
- Width: 10 mm
- Hole spacing: 12 mmand16mm
Limited Contact-Dynamic Compression Plate,

3.5 mm in Titanium
The design features of the LC-DCP, 3.5 mm are analogous to
those of the LC-DCP, 4.5 mm. See Sect.6.5.1.1. The plate is
smaller in size, and is applied with 3.5 mm titanium cortex
screws and 3.5 mm titanium shaft screws in the diaphysis, and
with 4.0 mm titanium cancellous bone screws in the metaphysis.
The 3.5 mm screws can be inserted in three different positions:
neutral, load, or buttress. For this purpose, special drill guides
have to be used, either the LC-DCP drill guide, 3.5 mm, or the
LC-DCP universal drill guide, 3.5 mm. See Sect. 6.9.1.1. Before
applying a LC-DCP, the plate must be contoured. The bending
templates are used as models.
The LC-DCP is used for the same indications as the DCP: fore-
arm fractures, fractures of the distal humerus, the clavicle and
-="'
-
the pelvis. It can be applied for any desired function as neutrali- ~
"S.
sation, tension band or buttress plate. e
-=e
"CC
The improved design offers certain advantages: ;
- Structured undersurface: The evenly distributed undercuts "'
reduces to a minimum the contact area between bone and ~
plate. This significantly improves the blood supply of the plat-

--==
-=e
ed bone segment, and has been shown to prevent local osteo- ""'
"'
porosis. The undercuts also allow for the formation of a small
callus bridge, which increases the strength of the bone at a ~
very critical location. The callus bridge may reduce the risk of ~
refracturing after implant removal. ~

- The enlarged cross-section at the plate holes and the reduced
cross-section between holes offer a constant degree of stiff-
191
•
I I
ness along the whole long axis of the plate. No particular
stress concentration occurs at the holes when the plate is ex-
posed to a bending load or during contouring of the plate
- Trapezoidal cross-section of the plate: The trapezoidal cross-
section of the plate results in a smaller contact area between
plate and bone. A broad and low bony lamella is formed
along the side of the plate, which is less likely to be damaged
at plate removal.
- Uniform spacing of plate holes: The plate holes are uniformly
spaced, which permits easy repositioning of the plate. The
screw holes are 7 mm long.
- Symmetrical spherical gliding holes: The basic principle of
spherical gliding of the screw head in the plate hole is pre- 'I'
~
served, but augmented. Both ends of the plate hole offer the
gliding possibility, which means more versatility in use. The
holes allow 0.75 mm displacement of the fragment, if a load
screw is inserted. Neutral screw placement gives minimal dis-
I
placement. t 7•
- Undercut plate holes: Undercuts at both ends of the plate
hole, allow 40 o tilting of screws either way along the long axis
of the plate. Lag screw fixation of short oblique fractures is
thereby possible. Screws can be tilted ±7 o in the transverse
plane. Furthermore, the undercuts reduce the contact area
between plate and bone even further.
- The articulated tension device may be hooked in the end
plate holes if further compression is necessary, i.e. in frac-
tures with a wider gap.
- The LC-DCP, 3.5 mm is available in lengths from 51 mm to
155 mm, with 4 to 12 holes.
-Profile: See figure
-Thickness: 4.0mm
- Width: 11 mm
-Hole spacing: 13 mm
- Hole length: 7 mm
Small T Plate, Right-Angled

~ This plate is designed for use on the volar aspect of the distal ra-
=
·;:c- dius. The plate is slightly concave and the head portion bent to ac-
.c commodate the volar surface of the distal radius. The plate may
IJ
~ exceptionally be used in certain fractures of the olecranon, the
] ankle, and the metatarsals. The head portion has either three or
: four holes, and the plate shaft three, four, five, or six holes. One
0
·.; hole is elongated to be used for an oblique lag screw, or for pre-
c= liminary adjustment of the plate. The shaft is fixed with 3.5 mm
e cortex screws and the head with 4.0 mm cancellous bone screws.
....2
-
•
~
192
--- Important dimensions:
- Profile:
- Thickness:
- Width:
See figure
1.2mm
10 mm
Small T Plate, Oblique

This plate is designed for the dorsal aspect of the distal radius.
Its 120 °-angled head conforms to the anatomical angle of the
bone and fits both the left and the right radius equally well. The
holes are made to accept the screw head on both sides. The plate
may be contoured by using small pliers and small bending irons.
The plate is available with 3 holes in the head and 3, 4, or 5 holes
in the shaft. Two shaft holes are elongated for lag screw fixation,
and for temporary fixation and adjustment of the plate. The
3.5 mm cortex screws are used in the shaft and 4.0 mm cancel-
-
lous bone screws in the head.
- Shaft profile: See figure
- Thickness: 1.5mm
- Width: 10 mm
Cloverleaf Plate
This plate has been developed for comminuted fractures of the
distal tibia to buttress its medial side, but may be used also in the
proximal humerus. The head portion can be contoured easily to
conform to the bone, and can be cut to the desired shape. The
holes in the head accept small fragment screws. The shaft is
fixed with 4.5 mm screws. In newly developed titanium plates it
will accept 3.5 mm cortex screws. In the future these will be
available in stainless steel as well. The elongated hole is used for
preliminary fixation to permit adjustment of the plate along the
axis of the bone.
The plate is presently available with 3 or 4 holes in the shaft, and
in lengths of 88 and 104 mm.
- Thickness: 1.2 mm (titanium 2.0 mm)
Kirschner Wires, 150 mm L ong

These wires of 1.25 mm diameter and 1.6 mm diameter are
available for temporary fixation of small fragments. The trocar
tip allows insertion with the small air drill using the Jacobs
chuck. Pre-drilling with a drill bit of the nearest dimension is
recommended in dense bone. The wires can be cut with a wire
cutting forceps if desired. Further sizes of Kirschner wires exist.
See SYNTHES catalogue.
193
•
6.9.2.3 Supplementary Implants
R econstruction Plates, 3.5 mm, Straight

These plates are used with 3.5 mm cortex screws. Their main ap-
plication is in pelvic and acetabular fractures. They may some-
times be used in fractures of the distal humerus (dorsolateral as-
pect), the clavicle, and the calcaneus. The reconstruction plates
have notches alongside the plate, which enables bending in
three dimensions. Special bending irons and pliers are available.
Bending angles greater than 15 oat any one site should be avoid-
ed. Note that the already low stiffness of the plate is further di-
minished by bending. If a strong curvature is needed, e. g. for the
pelvis, it is better to choose the pre-bent, curved reconstruction
plate. See Sect. 6.10.3.
The oval holes permit some self-compression if the screw is in-
serted eccentrically. The holes also accept 4.0 mm cancellous
bone screws if the plate is placed over cancellous bone area.
Screws can be inserted at an angle of approximately 25 o longitu-
dinally and 7 o sideways. The plates are available in lengths from
58 mm to 262 mm, with 5 to 22 holes.
- Thickness: 2.8mm
- Width: 10 mm
Cerclage Wires
These wires in dimensions 1.0 mm and 1.25 mm diameter are
sometimes used for the fixation of small fragments in the ankle,
the elbow and the wrist. Further sizes cerclage wires exist. See
SYNTHES catalogue.
6.9.2.4 Obsolete Implants
3.5 mm Cancellous Bone Screws, Fully Threaded

These screws are no longer manufactured. They have been re-
placed with the fully threaded 4.0 mm cancellous bone screws.
Y Plate
This plate with side notches was designed for condylar fractures
of the humerus. The plate could be bent in three dimensions to
conform to the bone. It was also possible to cut the plate to
desired size. The oval holes permitted some axial compression.
Due to its low stiffness and difficulties in its removal, because of
its Y shape, it is no longer manufactured. Fractures of the distal
humerus are better fixed with the existing straight small frag-
ment plates.
• 194
6.9.3 Fixation Techniques with Small Fragment Implants
6.9.3.1 Fixation Techniques with Small Fragment Screws
Small fragment screws are used as lag screws, plate fixation

screws, or as transfixing or positioning screws (3.5 mm cortex
screw). The principles of the fixation techniques are the same as
for the large screws, as are the principles of screw orientation.
See Sect. 6.4.1.4. The smaller the size of the instruments and im-
plants, the greater becomes the importance of precise tech-
nique.
4.0 mm Cancellous Bone Screw, Partially Threaded,

Used as Lag Screw
In fractures of the ankle, the elbow, and the wrist, 4.0 mm can-
cellous bone screws are often inserted as lag screws, either sepa-
rately or through a plate hole. Because of its deep thread,
smooth shaft and fairly large screw head, substantial interfrag-
mentary compression can be achieved. The thread must have
purchase in the far fragment only, the shaft allow gliding in the
near fragment, and the screw head must have a secure seat on
the bone surface. The position of the screw, if placed separately,
is more or less at right angles to the fracture plane.
Lag screw principle: The screw thread must have purchase in
the far fragment only.
Step by step procedure for the example of a shear fragment of
the lateral malleolus:
- The fracture is reduced with a pointed reduction forceps and
temporarily fixed with a Kirschner wire (Fig.l ).
- The thread hole is drilled using the 2.5 mm drill bit in the dou-
ble drill sleeve, 2.5 mm. If a Kirschner wire has been inserted
for reduction, parallel drilling is possible by placing the wire
through the hole near the sleeve (Fig. 2).
- A recess is cut in a thick cortex with the countersink (Fig. 3).
195 •
- In hard, juvenile bone the thread may have to be cut using the
tap for 4.0 mm cancellous bone screws in the double drill
sleeve end 3.5 mm (Fig. 5).
- The selected screw is inserted with the small hexagonal
screwdriver (Fig. 6).
5
- If the screw is inserted as a separate lag screw and the cortex is
thin, a washer is used to prevent the screw head from sinking
into the bone. The flat side of the washer is placed on the
bone, the recessed side in contact with the head.
- The Kirschner wire is cut, bent , and the end impacted in the
bone to secure the fixation (Fig. 7, 8).
4.0 mm Cancellous Bone Screw, Fully Threaded,

Used as Plate Fixation Screw
This screw is mainly used as a plate fixation screw for small frag-
ment plates located over cancellous bone area. Here, the wide
thread gives the screw good purchase. This screw is not used as a
lag screw, this function being served by the partially threaded
screw.
7
- The thread hole is drilled through the plate hole using the
2.5 mm drill bit in the double drill sleeve end, 2.5 mm.
- The cortex is tapped with the tap for 4.0 mm cancellous bone
- The selected screw is inserted with the small hexagonal
screwdriver. 8
3.5 mm Cortex Screw Applied as a Lag Screw
This screw is ideal for fixation of fragments in the diaphyses of

small bones such as the forearm, the fibula, and the clavicle. It is
also used in larger bones for the fixation of small fragments. A
lag screw technique must be used whenever the screw crosses a
"' fracture, even through a plate.
=
~
="
·=
.c Lag screw principle: The screw thread must have purchase in
~
~
"C
; Step by step procedure:
§ - The fracture is reduced and temporarily fixed.
-
·~ - The gliding or clearance hole is drilled in the near cortex
5 using the 3.5 mm drill bit and the double drill sleeve end,
S 3.5 mm (Fig.l).
2 - T he 2.5 mm end of the double drill sleeve is pushed into the
....
-It! gliding hole until it abuts the far cortex. The thread hole drilled
• 196
2.5
in the far cortex with the 2.5 mm drill bit through the sleeve
(Fig. 2). The insert sleeve 3.5 mm/2.5 mm may be used as an
alternative (Fig. 3).
- The countersink is used in areas where the screw head is seat-
ed upon thick cortex as a separate lag screw (Fig. 4).
3 - The thread hole is tapped with the tap for 3.5 mm cortex
screws in the double drill sleeve end, 3.5 mm (Fig. 6).
- The screw is inserted and tightened with the small hexago-
nal screwdriver. Interfragmentary compression is achieved
(Fig. 7).
3.5 mm Cortex Screw Applied as a Plate Fixation Screw
Any small fragment plate used for diaphyseal fractures is fixed

with 3.5 mm cortex screws. It should ideally have purchase in
both cortices, unless the screw crosses a fracture,.
- Using the 2.5 mm drill bit in the double drill sleeve end,
2.5 mm, the thread hole is drilled through both cortices.
- The drilled hole is tapped with the tap for 3.5 mm cortex
screws in the 3.5 mm double drill sleeve end.
- The screw is inserted with the small hexagonal screwdriver.
-="'
~
"S.
3.5 mm Cortex Screw Applied as a Transfixing ....e
- =
"CC
or Positioning Screw ~
="'
Transfixing the fibula to the tibia is indicated if, after internal
-.e=
~
fixation of a fibular fracture in a type C malleolar injury, the syn-

desmosis remain unstable. It may also be used in the type C sub-
capital fibular fracture (Maisonneuve fracture), when direct
....=
"'
fibular internal fixation is precluded. The screw engages at least
three cortices; two in the fibula and one in the tibia (three-point
=
e
~
contact). The position of the screw is approximately 4- 6 em ~

proximal to the ankle joint. It is inserted obliquely from back to
front at an angle of25 o - 30 °.1t is directed from the lateral to the
197
•
medial cortex of the fibula, and into the lateral cortex of the
tibia at right angles to the long axis.
A transfixing screw can also be inserted through a plate hole or
beside a plate.
Step by step procedure: ~-~-
- The fibular fracture is reduced, and provisionally transfixed
to the tibia with a horizontal1 .6 mm Kirschner wire.
- Using the 2.5 mm drill bit in the double drill sleeve end,
2.5 mm both cortices of the fibula (1 and 2) and at least one of
·:
~_- ' ·· •.• t' ... - '~ .
. Y '
the tibia (3) are drilled. A recess for the screw head must not 3,5 B I 2 C
be cut, since this may weaken the bone (A).
- With the fibula carefully held in its fully reduced position, the
fibular and tibial cortices are tapped using the tap for 3.5 mm
cortex screws in the double drill sleeve end, 3.5 mm (B) .
- Insertion of the appropriate cortex screw with the small D
hexagonal screwdriver (also through a plate if necessary).
The screw will not exert any compression as there is no glid-
ing hole, and all cortices have been tapped (D).
- Careful tightening of the screw.
3.5 mm Titanium Shaft Screw Used as a Lag Screw

in a LC-DCP, 3.5 mm
The shaft screw is designed as a partially threaded screw with a

shaft diameter of 3.5 mm. It therefore can be used as a lag screw
gaining purchase only in the far fragment. The smooth shaft en-
sures gliding in the near fragment. The shaft screw is mainly
used in the LC-DCP, 3.5 mm.
Lag screw principle : The screw thread must have purchase in
Thread Hole First Technique

Preparing the thread hole before the gliding hole ensures exact
position of the lag screw in the plate hole.
- The fracture is reduced and the plate fixed to the main frag-
ments.
- The thread hole is drilled through both cortices using the
2.5 mm drill bit in the LC-DCP universal drill guide, 3.5 mm.
The drill guide is pressed into the plate hole in the desired
direction. The neutral (green) LC-DCP drill guide, 3.5 mm,
with the arrow pointing towards the fracture, may also be
used.
- The screw length is measured with the depth gauge, 3.5-
4.0mm .
• 198
screws in the 3.5 mm end of the double drill sleeve, or of the
universal drill guide.
- Maintaining the direction, the thread hole is carefully over-
drilled in the first cortex with the 3.5 mm drill bit in one of the
3.5 mm guides mentioned above.
- The shaft screw is inserted with the small hexagonal screw-
driver.
Gliding Hole First Technique

- The fracture is reduced and the plate fixed to the main frag-
ments.
- The gliding hole is drilled in the near fragment adjacent to the
fracture using the 3.5 mm drill bit in the double drill sleeve,
3.5mm.
- The double drill sleeve is turned around and the 2.5 mm
sleeve pushed into the gliding hole until it abuts the endosteal
cortex of the far fragment.
- The thread hole is drilled in the far cortex with the 2.5 mm
drill bit through the 2.5 mm sleeve.
3.5-4.0 mm.
- The selected shaft screw is inserted with the small hexagonal
screwdriver. Interfragmentary compression is achieved.
The 3.5 mm Titanium Shaft Screw Applied as a Load Screw

inaLC-DCP
Since the smooth shaft has the same diameter as the thread it
provides improved stiffness and strength when the screw is
used, as load screw, for axial compression. For this application It
is possible to use either the LC-DCP drill guide, 3.5 mm, or the "'
=
-=
LC-DCP universal drill guide, 3.5 mm. ~
"S.
Step by step procedure: e
"C
- The plate is fixed to the bone with a neutral screw in the frag- ~
ment whose fracture surface forms an obtuse angle with the "'
underside of the plate. =
e
--=e=
~
- On the opposite side of the reduced fracture the LC-DCP 2

drill guide, 3.5 mm for compression is positioned in the plate "'
hole with the arrow pointing toward the fracture. The thread
hole is drilled through both cortices with the 2.5 mm drill bit. ~
This hole is now in eccentric position. ~

~
-e
~
';
II)
199 •
Variation:
- The LC-DCP universal drill guide, 4.5 mm is placed with its
protruding sleeve in eccentric position in the plate hole, away
drill bit.
- Tapping of the thread hole with the tap for 3.5 mm cortex
screw in the double drill sleeve end, 3.5 mm.
- The near cortex is carefully overdrilled with the 3.5 mm drill
bit in the double drill sleeve end, 3.5 mm.
- Insertion of the selected 3.5 mm titanium shaft screw with the
small hexagonal screwdriver. Interfragmentary compression
is achieved.
6.9.3.2 Fixation Technique with Small Fragment Plates
The fixation technique of an implant will depend upon the local

anatomy and the fracture type. The following examples serve as
guidelines only.
One-Third Tubular Plate Applied as Tension Band Plate

I
The plate is applied as tension band plate in certain short
oblique or transverse fractures, e. g. the fibula, the metatarsus,
the distal ulna and the olecranon.
Prerequisites:
- The plate is applied to the tension side of the bone.
- The plate is contoured to the shape of the bone using a tem-
plate as a model. In transverse fractures the plate is also
slightly overbent. Seep. 182.
- Axial compression is achieved by eccentric placement of
screws in the plate holes adjacent to the fracture.
2
Plate length:
- Five to six cortices in each main fragment should be engaged.
I
- After reduction the contoured and slightly overbent plate is
"'~ applied to the bone with reduction forceps .
·2' - The first screw hole is drilled in one of the plate holes near the
'5 fracture using the 2.5 mm drill bit in the double drill sleeve 3
~ end, 2.5 mm (Fig. 1).
-=; - The screw length is measured (Fig. 2).
= - The thread hole is tapped with the tap for 3.5 mm cortex
.::= screws in the double drill sleeve end, 3.5 mm (Fig. 3 ).
C - The selected 3.5 mm cortex screw is inserted with the small
e
~
~
hexagonal screwdriver, but not fully tightened (Fig. 4 ).
t: - The plate is then pulled towards the fracture to place this 4
-~ screw in the eccentric position .
• 200
I 1,5
6 7
- In the plate hole near the fracture in the opposite fragment,

the second screw hole is drilled with the 2.5 mm drill bit and
the double drill sleeve end, 2.5 mm. This drill hole is placed
in the eccentric (load) position, away from the fracture
(Fig.5, 6).
- If this screw comes to lie in cancellous bone a 4.0 mm fully
threaded cancellous bone screw is chosen. Tapping of the
thread hole with the tap for 4.0 mm cancellous bone screws in
the double drill sleeve end, 3.5 mm (Fig. 8).
- Insertion of the proper length fully threaded cancellous bone
screw. The first screw inserted and tightened (Fig. 9).
- The remaining plate screws are inserted alternating from one
side of the fracture to the other using the technique described
above.
- Final tightening of all screws (Fig.lO).
One-Third Tubular Plate Applied as a Neutralisation Plate

-=
c.=
"'
--
The one-third tubular plate is applied as a neutralisation plate in
spiral fractures or fractures with a butterfly fragment, e. g. in the 5
=
-=
=
fibula and the distal ulna. It is applied after primary interfrag-
mentary fixation with lag screws. The function of the plate is to = "'
neutralise any shearing or bending forces which could disrupt Q,l
--=..=
5
an unprotected lag screw fixation.
Prerequisites:
- Lag screw fixation first separately.
- Contouring of the plate. Seep. 182.
-= "'
Q,l
~
Plate length : ~
- Four to five cortices in each main fragment should be en-
gaged.
201
•
- The fracture is reduced and temporary fixation applied.
- A separate 3.5 mm cortex screw is inserted as lag screw in the
butterfly fragment using the technique described on p. 196.
- The plate site and shape is determined by means of a tem-
plate. The plate is then exactly contoured, and fixed to the
bone with forceps.
- The drill bit 2.5 mm in the double drill sleeve end, 2.5 mm is
used to drill the screw hole.
- The tap, 3.5 mm in the double drill sleeve, 3.5 mm is used to
cut the thread.
- The selected 3.5 mm cortex screw is inserted using the small
hexagonal screwdriver.
- The second plate screw is inserted in a similar manner on the
opposite side of the fracture.
- Alternating from one side to the other the remaining 3.5 mm
cortex screws are inserted.
- Should the plate end lie over cancellous bone, a 4.0 mm fully
threaded cancellous bone screw is used in the last plate hole.
The one-third tubular plate can also be applied as buttress plate
in certain fracture situations. All screws are then placed in the
buttress position, that is as near the fracture as possible in the
plate hole.
The DCP, 3.5 mm Applied as a Self-Compression Plate
The effect of self compression is used for axial compression of

short oblique, or transverse fractures of for example, the fore-
arm, clavicle, and pelvis (tension band plating).
Prerequisites:
- The plate is contoured to the bone, and in transverse fractures
slightly overbent. Seep. 182.
- Axial compression by one or more load screws.
Plate length:
- At least six cortices in each main fragment should be engaged.
"' Step by step procedure:
=
~
I:T'
·a - The fracture is reduced. The contoured plate is applied to the
-=
1.1 bone with the middle portion placed over the fracture, and
~ held with reduction forceps.
"C
= - In the plate hole adjacent to the fracture , the first screw hole
--=
~
=
.~
is drilled using the 2.5 mm drill bit in the DCP drill guide,
3.5 mm (Fig.1).
~
--=
e
~
- The tap for 3.5 mm cortex screw in the double drill sleeve end,
e 3.5 mm is used to cut the thread.
"'
• 202
- The chosen 3.5 mm cortex screw is inserted with the small
hexagonal screwdriver, but not fully tightened.
- The plate is pulled towards the fracture to place the first screw
in the eccentric position.
- The second screw hole is prepared in the plate hole adjacent
. .... to the fracture in the opposite fragment. The load (yellow)
2
DCP drill guide is placed in the plate hole with the arrow
pointing towards the fracture, The thread hole is then drilled
with the 2.5 mm drill bit (Fig. 2).
- The thread is cut with the tap for 3.5 mm cortex screw in the
double drill sleeve end, 3.5 mm.
- The 3.5 mm cortex screw is inserted with the small hexagonal
screwdriver. Tightening of the two screws produces axial
compression (Fig. 3).
- An addition load screw can be inserted if necessary.
3 - In the next plate hole the load (yellow) DCP drill guide,
3.5 mm is positioned with the arrow towards the fracture. The
hole is drilled with the 2.5 mm drill bit.
- The tap for 3.5 mm cortex screw in the double drill sleeve end,
3.5 mm is used to cut the thread.
- The 3.5 mm cortex screw is inserted until the screw head
'·-· ·
reaches the plate hole.
- Before the screw is tightened completely, the screw next to it
4 must be loosened to allow for further compression. After
tightening of this last load screw, the loosened screw can be
retightened (Fig.4).
- If the compression is sufficient, the remaining screws are
inserted alternating from one side to the other: Drill bit
2.5 mm in the neutral DCP drill guide, depth gauge, tap and
screw.
- Final tightening of all screws (Fig. 5).
- If any greater displacement is required than can be achieved
by three load screws (i.e. >3 mm), the articulated tension de-
vice should be used instead.
-="'
-
=..
~
DCP 3.5 mm Applied as a Self-Compressing Plate e

-=
=
-
with Lag Screw Through the Plate
~
"'
=
This technique is used in oblique fractures, where optimal sta-
e
..=
~
--=e=
bility can be achieved by combining the self-compressing effect
of the DCP for axial compression, and the interfragmentary -;;
compression of a lag screw.
~
Prerequisites:
~
- The plate is contoured to the bone and placed such that one E
1;1;,
plate hole can be used for the lag screw.
203
•
Plate length:
- Six cortices in each main fragment should be engaged by
screws.
- The fracture is reduced. The contoured plate is placed on the
bone with the wider middle portion over the fracture. A plate
hole is left vacant for an angled lag screw through the plate.
The plate is held in position by two reduction forceps.
- In the fragment which fracture surface forms an obtuse angle
with the undersurface of the plate, the drill bit 2.5 mm in the
neutral (green) DCP drill guide, 3.5 mm is used to drill the
first hole, near the fracture (Fig.1 ).
- The tap for 3.5 mm cortex screws in the double drill sleeve
end, 3.5 mm is used to cut the thread (Fig. 3).
- The 3.5 mm cortex screw is inserted but not fully tightened
(Fig. 4). The plate is pulled towards the opposite fragment to
place the screw in an eccentric position in the plate hole.
- On the opposite side of the fracture the first plate hole is left
vacant for the lag screw. In the next hole the load (yellow)
DCP drill guide, 3.5 mm is placed with the arrow pointing
towards the fracture. The thread hole then drilled with the 2
2.5 mm drill bit (Fig. 5).
- The thread is cut with the tap for 3.5 mm cortex screws in the
double drill sleeve, 3.5 mm (Fig. 7).
- The chosen 3.5 mm cortex screw is inserted (Fig. 8). Before
the screw is fully tightened, the first screw is driven home.
Axial compression is achieved.
- The position for the oblique lag screw through the plate is de-
termined. The angulation of the screw must not exceed ±25 °
longitudinally and ±7 o transversely. 3
- The gliding hole is drilled in the near cortex using the 3.5 mm
drill bit in the double drill sleeve end, 3.5 mm (Fig. 9).
- The 2.5 mm end of this sleeve is then pushed into the hole un-
til it abuts the endosteal cortex of the far fragment. The
thread hole is drilled with the 2.5 mm drill bit (Fig.10).
- After measuring and tapping, the chosen 3.5 mm cortex
"' screw is inserted and carefully tightened. Interfragmentary
g.~ compression is enhanced (Fig. 11).
] - The remaining screws are inserted one by one, alternating
~ from one side to the other: Drilling, measuring, tapping and
-= inserting the screw.
=~ - Final tightening of all screws (Fig.12). 4
=
--==
.~
...=
-
-
:I
• 204
5 9
6 10
11
-
c.
c"'
~
....e
"C
-e
c~
"'c
QJ
.......=
8 12 ........"'c
c
e
QJ
~
...
~
--e;
~
rJj
205
•
The DCP 3.5 mm Applied as a Compression Plate Using
the Articulated Tension Device. Lag Screw Through the Plate
Axial compression can be achieved by using the articulated ten-

sion device instead of the self compressing DCP holes. This is
recommended especially if the bone ends are markedly separat-
ed. Reduction of interdigitating fragments as well as fine rota-
tional adjustments is easier. If a plate screw crosses the fracture,
it should be inserted as a lag screw.
Prerequisites:
- Enough space for the articulated tension device on one side
of the fracture .
- Prebending ofthe plate (seep. 182).
Plate length:
- At least six cortices in each main fragment should be engaged.
- After preliminary reduction, the contoured plate is fixed to
the bone with reduction forceps.
- In the fragment which forms an obtuse angle with the under-
surface of the plate the first plate hole is drilled with the
2.5 mm drill bit in the neutral DCP drill guide, 3.5 mm. The
hole is measured, and then tapped with the tap for 3.5 mm
cortex screws in the double drill sleeve end, 3.5 mm. Then the
chosen 3.5 mm cortex screw is inserted. A second screw is in-
serted in this fragment using the same technique
- On the opposite side of the fracture, the opened articulated
tension device is hooked into the end plate hole. After
drilling, measuring and tapping through the foot-plate, the
device is fixed to the bone with a 3.5 mm cortex screw.
- The articulated tension device is carefully tightened using the
open end wrench. During tightening the fragments are ma-
noeuvred into correct alignment and rotation until they are
compressed.
- If a lag screw is to be inserted, the plate hole nearest the frac-
ture in the opposite fragment is used for this. The gliding hole
is prepared in the near cortex with the 3.5 mm drill bit in the
3.5 mm double drill sleeve end. The angulation of the screw
~ must not exceed ±25 o longitudinally, and ±7 o transversely.
=="' - The 2.5 mm end of the double drill sleeve is pushed into the
·a
.c gliding hole until it abuts the endosteal cortex of the far frag-
~
~ ment. The thread hole in the far fragment is prepared with the
-== 2.5 mm drill bit.
length is measured.
= -- The
~
--=
.::
=
The tap for 3.5 mm cortex screws in the double drill sleeve
end, 3.5 mm is used to tap the thread hole.
s - The chosen 3.5 mm cortex screw is inserted and interfrag-
--
~
2 mentary compression is achieved.

~
• 206
- Alternating from one side of the fracture to the other, the re-
maining screws are inserted using the neutral (green) DCP
drill guide, 3.5 mm and drill bit 2.5 mm.
- The articulated tension device is removed, and the screw in
the end plate hole inserted.
DCP, 3.5 mm Applied as a Neutralisation Plate
In spiral fractures of the diaphysis or in a fracture with a wedge

fragment, primary stability may be obtained by lag screws. A
neutralisation plate is applied to protect the lag screw fixation
from bending and shearing forces.
Prerequisites:
- Lag screw fixation of the main fragment.
- Exact contouring of the plate seep. 182.
Plate length:
- Five to six cortices in each main fragment.
- The reduced fracture is fixed with separate 3.5 mm cortex
screws as lag screws, using the technique described in
Sect. 6.9.3.1.
- The contoured plate is held to the bone with reduction for-
ceps.
- All screws are inserted in the neutral position using the
2.5 mm drill bit in the 3.5 mm DCP neutral (green) drill guide,
the depth gauge 3.5 mm- 4.0 mm, the tap for 3.5 mm cortex
screws in the double drill sleeve end, 3.5 mm, and the small
Note: The use of the load (yellow) DCP drill guide is not neces-
sary and may be dangerous. The force exerted could disrupt the
interfragmentary compression achieved by the lag screws in-
serted before applying the plate.
-=
"'
-
~
DCP, 3.5 mm Applied as a Buttress Plate "S.
e
A buttress plate protects a metaphyseal fragment from sec-
=
"CI
ondary collapse, or prevents shortening of a comminuted dia-
physeal fragment e. g. distal humerus fractures. -
~
"'
=
..=e
--
~
Prerequisites:
- Careful contouring of the plate seep. 182.
- All screws are inserted in the buttress position, avoiding com-
=
"'
pression.
e=
~
Plate length:
- Depends on the fracture localisation.
..
~
~
207
•
- The contoured plate is applied to the reduced fracture using
reduction forceps.
- In the main fragment, near the fracture, the double drill
sleeve end, 3.5 mm is placed in the plate hole so that it occu-
pies a "buttress" position. This is in the end of the plate hole
nearest the fracture. The thread hole is then drilled with the
2.5 mm drill bit in the double drill sleeve end, 2.5 mm.
- The thread is tapped using the tap for 3.5 mm cortex screw in
the double drill sleeve end, 3.5 mm.
- The next screw is inserted in the opposite fragment, in the
plate hole nearest the fracture. This screw hole is also pre-
pared in buttress position using the same technique as for the
first screw.
- All remaining plate screws are inserted in the buttress posi-
tion alternating from one side of the fracture to the other.
- If the plate end is positioned over a cancellous bone area, the
fully threaded 4.0 mm cancellous bone screw is used.
The LC-DCP, 3.5 mm Applied as Compression Plate

with Lag Screw Through the Plate
In an oblique fracture, the plate can be applied to achieve both

axial and interfragmentary compression by inserting a load
screw and a lag screw through the plate. The uniform hole spac-
ing and the evenly distributed stiffness along the plate makes
positioning and contouring of the plate easier. Titanium screws
are used in titanium plates.
Prerequisite:
- Pre bending of the plate seep. 182.
Plate length:
- Each main fragment must have screws anchored within at
"' least six cortices, and the screws must be spaced as evenly as
=
~
="
possible.
~ - Plate holes can be left free if necessary, or occupied with a
short, single-cortex screw.
~
'"CI
; Step by step procedure:
= - The fracture is reduced, and the pre-bent plate temporarily
= fixed to the bone with reduction forceps. The plate is posi-
3
= tioned carefully, and one screw hole in the middle left vacant
-.es
~
El for the lag screw.

- The first screw is inserted near the fracture in the fragment
which fracture surface forms an obtuse angle with the under-
• 208
surface of the plate. The neutral (green) LC-DCP drill guide,
3.5 mm is placed in the plate hole with its arrow pointing to-
wards the fracture. The thread hole is drilled with the 2.5 mm
drill bit (Fig.l ).
screws in the 3.5 mm end of the double drill sleeve.
- The chosen 3.5 mm titanium cortex screw is inserted with the
small hexagonal screwdriver, but not fully tightened.
- The plate is pulled towards the fracture, which places this
screw in an eccentric (load) position.
- The plate hole nearest the fracture in the opposite fragment is
left vacant for the lag screw. In the adjacent, suitable plate
hole the LC-DCP load (yellow) guide, 3.5 mm is placed with
the arrow pointing towards the fracture. The thread hole is
drilled with the 2.5 mm drill bit (Fig. 2).
- After measuring the length, the far fragment is tapped with
2 the tap for 3.5 mm cortex screws in the double drill sleeve
end, 3.5 mm.
the double drill sleeve end, 3.5 mm. A shaft screw is used for
maximum screw strength for the axial compression.
- The chosen 3.5 mm titanium shaft screw is inserted and fully
tightened, but only after the screw in the opposite fragment
has been driven home. Axial compression is achieved.
Note: A second and even a third load screw can be inserted if
further compression is necessary using the same technique just
described. Before tightening the screw, the adjacent load screw
3 has to be loosened.
- The thread hole for the lag screw is now prepared in the plate
hole which was left vacant. The LC-DCP universal drill guide,
3.5 mm is pressed into the plate hole in the desired direction.
This ensures a congruent fit between screw head and plate
hole. Both cortices are drilled with the 2.5 mm drill bit
(Fig.3).
After measuring, the hole is tapped with the tap for 3.5 mm
4 cortex screws, in the 3.5 mm end of the universal drill guide.
the 3.5 mm end of the universal drill guide.
- The chosen 3.5 mm titanium shaft screw is inserted. Inter-
fragmentary compression is achieved (Fig. 4).
- The remaining screws are inserted using the neutral LC-DCP
drill guide, 3.5 mm.
Variation 1
The LC-DCP universal drill guide, 3.5 mm can be used instead
of the LC-DCP drill guide for all screw holes. The neutral posi-
tion for screws is obtained by pressing the guide into the plate
209
•
hole. The load position is obtained by positioning the protrud-
ing tip of the inner sleeve in the plate hole eccentrically, away
from the fracture.
Variation2
The articulated tension device may be used with the LC-DCP,
whenever larger compression is required, i.e. in widely separat-
ed fractures, in porotic bone in some pseudarthroses, or in
metaphyseal applications. The LC-DCP is fixed first to the frag-
ment whose fracture surface forms an obtuse angle with the un-
dersurface of the plate. The plate is fixed with at least two
screws. Then the open articulated tension device is mounted in
the opposite end of the plate, and the foot-plate fixed to the
bone with a 3.5 mm cortex screw. Axial compression is achieved
by carefully tightening the bolt of the device. The remaining
screws in this fragment are inserted before the tension device is
loosened and removed. The screw used to fix the device should
be discarded and not used, as it has been stressed. See alsop. 206.
2
LC-DCP, 3.5 mm Applied as a Neutralisation Plate
In spiral fractures, or fractures with a wedge fragment, a LC-

DCP, 3.5 mm may be used instead of a DCP, 3.5 mm. Because
of its uniform hole spacing positioning of the LC-DCP may be
easier. Titanium screws are used with titanium plates.
Prerequisites:
- Lag screw fixation of the fracture prior to plate application.
- Exact contouring of the plate see p.l82.
Plate length:
- At least six cortices in each main fragment should be fixed by
screws. The quality of the bone finally determines the num- 3
ber of screws.
- The fracture is reduced, and fixed with either 3.5 mm or 2.7
mm cortex screws as separate lag screws. See pp. 178 and 249.
- The carefully contoured plate is applied to the bone with two
<l:l
~ reduction forceps.
·2' - The first screw is inserted in one of the main fragments with-
'5 out crossing the fracture. The 2.5 mm drill bit in the 3.5 mm
~ LC-DCP drill guide is used to drill the thread hole (Fig.l).
-=; - The screw length is measured with the depth gauge (Fig. 2).
= -
.~
The hole is tapped with the tap for 3.5 mm cortex screws in
-; the double drill sleeve end, 3.5 mm (Fig. 3 ).
•
C: - Insertion of the 3.5 mm titanium cortex screw with the small 4
-..==
Q,j
E hexagonal screwdriver (Fig. 4).
<l:l
....
• 210
- The second 3.5 mm titanium cortex screw is inserted in the
opposite main fragment using the same technique (Fig. 5).
- The remaining screws are inserted alternating from one side
of the fracture to the other The neutral (green) LC-DCP drill
guide, 3.5 mm in the 2.5 mm drill bit is used to drill the thread
hole. Measuring and tapping of the thread hole. Insertion of
the screw (Fig. 6).
Note : Not all plate holes need to be occupied with screws. A
short screw can be inserted, if the fracture location requires.
5
LC-DCP, 3.5 mm Applied as a Buttress Plate
Similar to the DCP, 3.5 mm, the LC-DCP, 3.5 mm can be used as
a buttress or as a bridging plate to prevent fracture zone collapse
in, for example the forearm.
Prerequisites:
- Careful contouring of the plate seep. 182.
- All screws should be inserted in buttress position to avoid
compression.
Plate length:
- Depends on the fracture localisation.
7 ~:t:I~GU:•2ilii:t:i=:::==:1:J - The fracture is reduced and the contoured plate applied to the
bone with reduction forceps, holding the bone out to length.
- The first screw is inserted near the fracture using the neutral
LC-DCP drill guide, 3.5 mm with the arrow pointing away
drill bit.
- The screw length is measured and the hole tapped with the
tap for 3.5 mm cortex screws in the double drill sleeve end,
3.5mm.
- The chosen 3.5 mm titanium cortex screw is inserted with the
small hexagonal screwdriver and tightened firmly.
- In the opposite fragment the procedure is repeated: Using
-]"=
"'
ell
the neutral (green) LC-DCP drill guide with the arrow point- ....
-=
"CC
ing away from the fracture the thread hole is drilled, mea- ell
sured, tapped, and the 3.5 mm titanium cortex screw inserted. "'
- If required, a lag screw can be inserted through the plate. De- =
e
~
pending on the location it may be a cortex or a cancellous

bone screw.
- The remaining screws are inserted in the buttress position us-
-=
2
...."'
ing the technique described for the first screw.
=~
~
~
...
ell
211 •
Application of Small T Plates
The small T-plates are mainly used for buttressing fractures in

the distal radius. If a screw crosses the fracture it should be in-
serted as a lag screw.
Prerequisites:
- Exact contouring of the plate to the bone surface using pliers.
Plate length:
- Three, four, or five screws in the shaft fragment will depend
on the extent of the fracture complex.
- Preliminary reduction of the fracture, usually with Kirschner
wires.
- The contoured plate is temporarily applied to the main frag-
ment with a screw in the oval hole. The drill bit 2.5 mm in the
double drill sleeve end, 2.5 mm is used to drill the thread hole.
- The thread hole is tapped in both cortices with the tap for
3.5 mm cortex screws in the double drill sleeve end, 3.5 mm.
- The 3.5 mm cortex screw is inserted with the small hexagonal
screwdriver, but not fully tightened.
- Final reduction is carried out, and the plate position adjusted.
The screw in the oval hole is tightened (Fig.l ).
- The plate head is fixed with 4.0 mm cancellous bone screws.
The drill bit 2.5 mm in the double drill sleeve end, 3.5 mm is
used to prepare the thread hole.
- Measuring and tapping.
- If the screw crosses a fracture, a partially threaded 4.0 mm
cancellous bone screw is inserted as a lag screw (screw thread
only in the far fragment). If the screw does not cross the frac-
ture a fully threaded 4.0 mm cancellous bone screw is used.
- The shaft is fixed with 3.5 mm cortex screws using the same
technique described for the first screw.
- Final tightening of all screws (Fig. 2). 2
Application of the Cloverleaf Plate
:; The cloverleaf plate is mainly used as a buttress plate in the dis-

& tal tibia. Bone graft is inserted in any metaphyseal defect. The
·a plate is fixed with small fragment screws in the head portion and
-5
~ 4.5 mm cortex screws in the shaft. If the recent introduced tita-
"C nium cloverleaf plate is used, the shaft accommodates 3.5 mm
= cortex screws in the diaphysis.
-=
~
=
·=....
~
Prerequisites:
Q,l
- Careful contouring and trimming of the plate, to the desired
shape. This can be achieved by removing selected lugs with a
....~ plate-cutting forceps if necessary.
~
"'= - Lag screws through the plate whenever possible.
• 212
Plate length:
- Three or four holes in the shaft, depending on the fracture
pattern.
- The fracture is reduced and temporarily fixed with Kirschner
Wires.
- The contoured plate is applied and fixed to the shaft with re-
duction forceps.
- Separate lag screws (mainly 4.0 mm cancellous bone screws)
are inserted in the metaphyseal zone, replacing some of the
Kirschner wires. (See technique, p. 195.)
- In the distal portion of the plate in one of the holes, the
2.5 mm drill bit in the 2.5 mm double drill sleeve end is used to
drill the thread hole.
- The screw length is measured and the near cortex tapped with
the tap for 4.0 mm cancellous bone screws in the 3.5 mm dou-
ble drill sleeve end.
- The chosen 4.0 mm cancellous bone screw is inserted with the
small hexagonal screwdriver. A partially threaded 4.0 mm
cancellous bone screw is inserted as a lag screw (the thread
only in the far fragment), if a fracture line is crossed, other-
wise a fully threaded screw is used.
- The plate is fixed to the shaft with either 4.5 mm cortex screws
(stainless steel plates) or 3.5 mm cortex screws (titanium
plates) (Fig.1 ).
- If necessary, bone graft is applied.
- Further plate holes in the head portion are fixed with 4.0 mm
cancellous bone screws. It is not always necessary to fill all the
holes.
- Constant attention is given to the correct position of each in-
dividual fragment while applying the plate.
- If suitable, the oval hole can be used to insert an angled lag
screw (Fig.2).
Note: If stainless steel cloverleaf plates are used, the basic in-
2 strumentation is also needed.
Application of 3.5 mm Reconstruction Plate
Although the name implies that the plate is used for reconstruc-
tion as a buttress or bridging plate, it can also be used for com-
pression in the diaphysis and especially in pelvic fractures. The
oval holes allow eccentric positioning of screws, which can be
used to achieve some axial compression as the following exam-
pleshows.
Prerequisites:
Three-dimensional bending must not exceed 15 oat any one site
in any plane. The relatively low strength of the plate is otherwise
further diminished and the plate holes may be distorted.
213 •
Plate length:
In general six cortices in each main fragment.
- The fracture is reduced, and the carefully contoured plate ap-
plied to the bone with reduction forceps.
- The 2.5 mm drill bit in the 2.5 mm double drill sleeve end is
used to drill the first thread hole near the fracture.
- The tap for 3.5 mm cortex screws in the 3.5 mm double drill
sleeve end is used to cut the thread.
hexagonal screwdriver but not fully tightened. The plate is
pulled toward the fracture to place this screw in an eccentric
position.
- On the other side of the fracture in the plate hole closest to
the fracture the 2.5 mm double drill sleeve end is placed ec-
centrically away from the fracture. The thread hole is drilled
with the 2.5 mm drill bit.
- The length is measured, and the thread hole tapped using the
tap for 3.5 mm cortex screws in the 3.5 mm double drill sleeve
end.
- The chosen 3.5 mm cortex screw is inserted and fully tight-
ened, once the first screw has been driven home. This pro-
duces axial compression.
- The remaining screws are inserted in the neutral position us-
ing the 2.5 mm drill bit in the 2.5 mm double drill sleeve end.
After measuring and tapping, the screws are inserted.
Note: Any screw crossing the fracture should be inserted as a lag
screw (the thread only gripping the far fragment).
Note: If the plate end overlies cancellous bone, a fully threaded
4.0 mm cancellous bone screw is used to fix the plate.

of Small Fragment Implants
Instruments for the insertion of 4.0 mm cancellous

bone screws
• 214
Instruments for the insertion of 3.5 mm cortex screws (fully
threaded and shaft screws)
Instruments for the application of DCP, 3.5 mm
-
·="'
=..
~
....e
-=
"C
~
"'
=
e
~
....=
.....
-"'
....=
=
e
~
~
~
.....
-r..e
';
rrJ
215
•
Instruments for the application of LC-DCP, 3.5 mm
I I
, Instruments for the application of one-third tubular plates,

small T plates, reconstruction plates, and cloverleaf plates
"'
Q,j
·a.c=-=
Col
~
=
"C
eo:
Instruments for the removal of small fragment implants.
--=
=
.~
eo:
- The screw head recess is carefully cleaned of debris, and the
small hexagonal screwdriver used to remove the screws. If
traction has to be applied to remove, for example, partially
e
Q,j
.s-
threaded screws, the screw-holding sleeve is employed.
2 Small fragment plates are in general easy to loosen with a
"' periosteal elevator, and can thereafter be removed .
• 216
6.10 Pelvic Instruments and Implants
Since internal fixation of pelvic and acetabular fractures has be-

come more common, special instruments and implants have
been developed.
6.10.1 Instruments for Screws and Plates
The instruments listed below will be available in either a graph-

ic case or in a sterilising tray in the future. These sets have to be
used in combination with the basic instrument set and the small
fragment instrument and implant set.
Drill Bits, 3.5 mm and 4.5 mm Diameter

These bits, 195 mm/170 mm, with quick coupling end, are used
to pre-drill for long 3.5 mm and 4.5 mm cortex screws. They are
used with the drill guide from the standard sets corresponding in
size.
Drill Bits, 2.5 mm and 3.2 mm Diameter, Three-Fluted,

and Calibrated
These bits, 230 mm/205 mm, have quick coupling ends. They
are used when drilling at oblique angles, since the likelihood of
skidding off the bone is reduced by the three cutting edges. The
drill bits are used with the drill guides or sleeves from the stan-
dard sets corresponding in size. The calibration permits control
ofthe drilling depth from 30 to 200 mm in 10 mm steps. Two ring
markings indicate 100, 150 and 200 mm drilling depths. Three
rings indicate 250 mm.
------------r....,. Drill Bit, 4.5 mm Diameter, Three-Fluted

This bit, 195 mm/170 mm, with quick coupling end, is used to
drill the gliding hole for 4.5 mm cortex screws in a deep wound.
The double drill sleeve, 4.5 mm/3.2 mm, from the basic instru-
-="'
-
ment set is used as tap sleeve. ~
Q.
e
··•·· u Depth Gauge, 3.5- 4.0 mm
=
-=
This gauge is used for measuring small fragment screws up to
110 mm. The design and function is similar to that of the depth
~
-
"'
=
e
--=
~
gauges in the basic set or in the small fragment instrument and

2
implant set.
"'
·::
1.1
1l
=-
217 •
Tap for 3.5 mm Cortex Screws, Calibrated .
This tap is 175 mm long and has a 50 mm thread length. It is used
to cut the thread before inserting 3.5 mm cortex screws longer
than 50 mm. The double drill sleeve, 3.5 mm/2.5 mm, from the
small fragment instrument and implant set is used as tap sleeve.
The tap has a quick coupling end and is used with the T handle in
the standard sets. The calibration permits control of the tapping
depth from 60 to 140 mm in 10 mm steps.
Tap for 4.5 mm Cortex Screws, Calibrated

This tap is 175 mm long and has a 50 mm thread length. It is used
to cut the thread in bone when inserting long 4.5 mm cortex
screws. The double drill sleeve, 4.5 mm/3.2 mm, from the stan-
dard basic set is used as tap sleeve. The tap has a quick coupling
end and is used with the T handle from the basic set. The calibra-
tion permits control of the tapping depth from 60 to 140 mm in
10 mmsteps.
Large Hexagonal Pelvic Screwdriver, 300 mm

This screwdriver, 3.5 mm in width across flats, is used to insert
4.5 mm cortex screws and 6.5 mm cancellous bone screws in
deep wounds. The screwdriver shaft has a groove to lock the
large holding sleeve.

This is a self-retaining screw-holding sleeve which connects to
the large hexagonal pelvic screwdriver and large shaft. The
holding sleeve holds the large screws securely during insertion
in a deep wound.
Large Hexagonal Pelvic Screwdriver Shaft

This shaft, 3.5 mm in width across flats and 165 mm long, may be
connected to the small air drill and used to insert 4.5 mm cortex
screws and 6.5 mm cancellous bone screws in deep wounds.
Small Hexagonal Pelvic Screwdriver, 270 mm

"'~
·a
This screwdriver, 2.5 mm in width across flats, is used when in-
serting small fragment screws in a deep wound. The screwdriver
'5 shaft has a groove to lock the small holding sleeve in position.
~
=
~
Small Holding Sleeve
=
=
;
0 This is a self-retaining screw-holding sleeve which connects to
~ the small hexagonal pelvic screwdriver and the small shaft. The
= small fragment screws are securely held by the sleeve during in-
a
~
sertion in a deep wound.

....2
-=
•
"'
218
Small Hexagonal Pelvic Screwdriver Shaft
This shaft, 2.5 mm in width across flats and 165 mm long, may be
connected to the small air drill and used to insert small fragment
screws in deep wounds.
Bending Template for Straight Reconstruction Plates, 4.5 and

• • • • • • • • • • • • • • • • • • • • • • 3.5 mm, and for Curved Pelvic Reconstruction Plates, 3.5 mm
These templates are made of anodised aluminium and easily
moulded to conform to the shape of the bone. They are used as
models when contouring reconstruction plates. They have in-
dentations at the edges similar to those of the reconstruction
plates corresponding in size.
Bending Irons for Reconstruction Plates, 3.5 mm and 4.5 mm

These irons are used in pairs for two-dimensional contouring
and twisting of3.5 mm and 4.5 mm reconstruction plates. Bend-
ing "on the flat" can be performed by placing the plate onto the
special pegs. Twisting can be achieved using the other end.
Bending Pliers for Reconstruction Plates 2. 7 mm and 3.5 mm

These pliers are designed to allow three-dimensional bending
without exceeding the permitted 15 ° at any one side.
Pelvic Osteotomy Chisels

These chisels, 304 mm with 15 mm and 20 mm blade widths, are
designed for periacetabular osteotomies in the treatment of hip
dysplasia. The chisel is angulated 4 em beyond the cutting end.
It has a half-moon shaped groove with blunt ends on the tip of
the blade, which helps to protect the soft tissue when cutting os-
teotomies blind. For cutting, the chisel has to be pushed towards
the bone in a direction parallel to the blade.
219
•
Combined Depth Gauge for 3.5--6.5 mm Screws

This depth gauge measures up to 150 mm. It is used to measure
the length for the long 3.5 mm and 4.5 mm cortex screws and the
long 6.5 mm cancellous bone screws included in the pelvic im-
plant set.
6.10.3 Pelvic Reduction Instruments
Pelvic reduction instruments are available in either a graphic

case or in a sterilising tray.
Straight Ball Spike, 300 mm

This spike is used to push bone fragments carefully into place.
Blunt Pelvic Retractor

This retractor has a round tip to prevent any damage to viable
structures when used in pelvic surgery.
Oblique Pelvic Reduction Forceps, Small, 190 mm,

and Large, 230 mm, Pointed Ball Tips
The oblique jaws of these forceps permit reduction while posi-
tioning the handles away from the centre of the wound, and the
line of vision. The pointed ball tips of all these forceps provide a
secure hold in bone, while the 8 mm balls prevent over-penetra-
tion of thin bone. In addition, the balls fit in the holes of a
4.5 mm DCP or LC-DCP. This allows the use of the plate as are-
duction aid to distribute forces over a larger area. The point pro-
jects beyond the undersurface of the plate into the bone to pre-
vent slipping.
"'
=
~
1:7'
] Pelvic Reduction Forceps, 400 mm, Pointed
~ and Three Pointed Ball Tips
"C
c The long jaws of these two forceps permit reduction deep into
~
c the pelvis around large fragments of the ilium. The long handles
-=e
.~
~ increase the leverage.
~
-....e
~
• 220
Pelvic Reduction Forceps, 250 mm,
with Angled Pointed Ball Tips
This forceps is applied when reducing fractures of relatively flat
bones where soft tissue limits access to the fracture. The angled
tips afford better grip and prevent slippage.
Spiked Disc
This disc attaches to the ball tip of any of the above reduction
forceps. It disperses the forces of the forceps by providing a
greater contact area, reducing the risk of penetrating thin bone.
The disc swivels on the ball-tip; the seven points prevent slip-
page. It is attached by placing the disc on a hard surface and
pushing the tip of the forceps through the centre hole.
Small Pelvic Forceps,l90 mm, and Medium Pelvic Forceps,

250mm
These forceps are reduction forceps of Faraboeuf type used for
reduction by applying the forceps to screws inserted in the dif-
ferent fragments. The jaws have a cut-out to grip around the
screw head.
Pelvic Reduction Forceps, 330 mm

This forceps is used in conjunction with two screws for reduc-
tion, for example, of pelvic and acetabular fractures and for sym-
physis ruptures. Two screws are fully inserted in the two frag-
ments at a distance of no more than 80 mm apart. After releasing
the screws slightly the tips of the forceps may be attached.
Both compression and distraction can be exerted by changing
the speed-lock from the outer side of the handle to the inner side.
221 •
This forceps with ratchet may be used for the reduction of pelvic
and acetabular fractures, applied directly to the bone surface, to
shallow drill holes through the cortex or to the anchoring rings
or hooks.
Anchoring Hooks, Small and Large

These hooks may be hooked around the iliac crest or in the bone
and hold one arm of the pointed reduction forceps when reduc-
ing a pelvic fracture.
Anchoring Ring
This ring, 20 mm in diameter, made of polyoxymethacrylate
(POM) is used with the pointed reduction forceps to reduce
pelvic fractures. It is fixed with either a 4.5 mm cortex screw or
6.5 mm cancellous bone screw to the iliac wing fragment, where
placing a pointed reduction forceps is difficult. If necessary, a
second ring may be placed in the other fragment. The pointed
reduction forceps is then attached to the two rings and used to
squeeze the fragments together.
Bone Hook
The hook, medium and large, may be used for reduction of
pelvic fractures. See alsop. 361.
Universal Chuck with T Handle

This chuck is used with the Schanz screw, 6.0 mm, to reduce
fragments.
Schanz Screw, 6.0 mm Diameter, 190 mm

This flat-tipped screw, with a core size of 4.1 mm and a 50 mm
thread length, is used with the universal chuck with T handle to
reduce fragments. Inserted into the ischium, it can be used to
"'
~ control rotation of the posterior acetabular column.
C"'
·a
.c
IJ
~
"C
c
c =
-e
0
·..::
=
c
--e
~
"c'
• 222
6.10.4 Pelvic C Clamp
This clamp may be applied in unstable injuries to the pelvic gir-

dle associated with massive blood loss to prevent fatal shock be-
fore adequate therapeutic measures can be initiated. It permits
rapid reduction and stabilisation of the posterior part of the
pelvic girdle. It is not intended for use as a permanent or defini-
tive fixation device. In case of fracture of the sacrum or rupture
of the sacroiliac joint with concomitant blood loss from the frac-
ture surface, the use of the emergency pelvic C clamp can save
life. Direct transverse compression of the sacroiliac joint re-
duces the bleeding. The rare case of arterial bleeding, however,
is hardly affected. In such a case interventional radiology or
even internal iliac ligation may be needed.
The pelvic C clamp can be applied as an emergency measure in
the emergency room, too, on any table. lts application, however,
requires experience, and great care is recommended when han-
dling the instrument.
The components of the pelvic C clamp can be obtained in aster-
ilising tray. The components are:
- Two pointed nails, 223 mm long, 10 mm in diameter, with col-

lar and two nail elongations
- Two 40 em long side struts with threaded tubes
- A 50 em rail, a 25 em extension rail, and a connecting screw
Instruments necessary for application:

- Socket wrench with hammer -=
fl.)
-=e
"S.
"C
- Combination wrench, 11 mm
~
-=e
"'
--==
~
...
f l.)
- Large hexagonal screwdriver C.l

·;:
~
=-
223
•
Step by step application:
- The patient is in supine position, with pelvis and hips pre-
pared and draped, if possible.
- The posterior superior iliac spine (PSIS) is palpated, and an
imaginary line drawn between the PSIS and anterior superior
iliac spine (ASIS). The nail insertion point is on this line, ap-
proximately 3 to 4 fingerwidths anterolateral to the PSIS in
the average patient. This point is also on an extension of the
line of the proximal femur and of the greater trochanter in
neutral hip rotation (Fig.l).
- The nails are inserted into the threaded tubes in the side
struts of the assembled C clamp (Fig. 2) and pushed through
the stab incisions until the nails engage the bone. This will 2
prevent dorsal slippage on the sharp iliac edge.
Note: The nails must not be placed too ventrally, as this may
cause perforation of the thin part of the ilium.
- The side struts are pressed together by applying force on the
struts near the rail (Fig. 3).
- At this stage a cranial displacement can be simultaneously re-
duced by pulling on the leg. 3
- Dorsal displacement may be reduced by inserting a Stein-
mann pin into the ASIS and rotating one side of the pelvis
(one of the pelvic fragments).
- The nails, with the nail elongations, are further inserted using
the socket wrench hammer and the struts adjusted until
stopped by the shoulders (Fig. 4).
- The threaded tubes are tightened using the combination
wrench or, after removal of the nail elongation, with the sock-
et wrench. This locks the side struts on the rail and compres-
ses the dorsal segment of the pelvic ring (Fig. 5).
- The extension rail may be removed if the struts are placed on
the main rail (necessary in, for example, CT scanning). The
large hexagonal screwdriver is used to tighten and retighten
the connecting screws.
- The pelvic C clamp can be positioned either caudally, e. g., for
a laparotomy, or cranially for angiography (Fig. 6).
Note: The pelvic C clamp is not designed for comminuted frac-

"'~ tures of the ilium in the proximity of the sacroiliac joint because
·a;.
5
the nails cannot be adequately secured in the comminuted area.
'5 There is also a danger of pressing the fractured ilium medially
~ across the sacrum.
-== - Insertion of the nail too distally endangers the sciatic nerve
--=
eo::!
·==
and the gluteal vessels.
eo::!
- In the case of osteoporotic bone and incorrect positioning of
the nails excessive compression can force the nail too far into
..-e=
~
the bone. 6
r iJ
....
=
• 224
- The nail insertion sites must be meticulously disinfected and
dressed. The pelvic C clamp should be replaced as soon as
possible by a definitive fixation.
- Should the patient have to be moved he/she should on no ac-
count be placed on the side as this could cause one of the nails
to penetrate the bone excessively.
6.10.5 Pelvic Implants
For the fixation of pelvic and acetabular fractures the standard

implants contained in the basic implant sets and the small frag-
ment instrument and implant set (see Sect. 6.9) are used. In ad-
dition to these implants, longer screws and a variety of plates are
available in a special pelvic implant set. The application of these
implants is similar to that of their counterparts. See Sects. 6.4.,
6.5 and 6.9. They do, however, sometimes require the longer in-
·: 1 .. .
I 0 • I struments described in Sect. 6.10.1.
These additional pelvic implants are available in either a graph-
ic case or in a sterilising tray.
Cortex Screws, 3.5 mm

These 3.5 mm cortex screws in lengths from 55 to 110 mm, in
5 mm increments, are used separately or for the fixation of
3.5 mm implants in pelvic fractures where deep anchoring of the
implant is necessary. The long drill bits and taps are used. For
details see Sect. 6.9.2.1
Cortex Screws, 4.5 mm

The 4.5 mm cortex screws are available in lengths from 72 to
80 mm, in 4 mm increments, and from 85 to 110 mm, in 5 mm in-
crements. The long instruments are required for the insertion.
For details see Sect. 6.4.1.
Cancellous Bone Screws, 6.5 mm, with 16 mm and 32 mm

Thread Length
These screws are available in lengths of 115 mm and 120 mm.
Cancellous Bone Screws, 6.5 mm, Fully Threaded

These screws are available in lengths of 45, 50, 55, and 60 mm.
Reconstruction Plates, 3.5 mm, Straight

These plates are used with 3.5 mm cortex screws. Their main ap-
plication is in pelvic and acetabular fractures. They may also be
used in fractures of the distal humerus (dorsolateral aspect), the
clavicle and of the calcaneus.
225
•
The reconstruction plates have lateral notches between the
holes, which enables twisting and bending in two dimensions.
Special bending irons and pliers are available. Bending angles
greater than 15 oat any one site should be avoided. Note that the
already low stiffness of the plate is further diminished by bend-
ing. If a strong curvature is needed, for example, for the pelvis, it
is better to choose a prebent, curved reconstruction plate. See
below.
The oval holes permit some self-compression if the screw is in-
serted eccentrically. The holes also accept 4.0 mm cancellous
bone screws if the plate is placed over cancellous bone area.
Screws can be inserted at an angle of approximately 25 olongitu-
dinally and 7 o sideways.
The plate is available in lengths from 58 to 262 mm, with 5 to
22holes.
- Thickness: 2.8mm
- Width: 10 mm
Reconstruction Plates, 3.5 mm, Curved

These plates are especially designed for fractures of the anterior
column of the pelvis. They are slightly thicker than the straight
plate and are precurved. The design and application is other-
wise similar to that of the straight reconstruction plate.
The curved reconstruction plate, 3.5 mm, is available with 6 to
18 holes, in lengths from 70 to 214 mm.
- Profile: See figure I
- Thickness: 3.6mm ~
-Width: 10 mm
- Bending radius: 100 mm
Reconstruction Plates, 4.5 mm, Straight

These plates are similar in design to the 3.5 mm reconstruction
"'~
·a.:
plates, only larger and used with 4.5 mm cortex screws. This
plate is chosen in very tall or heavy patients instead of the small-
tj erone.
~ The reconstruction plate, 4.5 mm, is available with 3 to 16 holes,
~
c in lengths from 45 to 253 mm.
=
--e=
c
.~
cQ,j
- Profile :
- Thickness:
See figure
2.8mm
-
2
....
~
-
-
Width:
Hole spacing:
12 mm
16 mm
• 226
Narrow DCP, 4.5 mm, Two Holes
This is a regular DCP, 39 mm long, used for the treatment of, for
example, symphyseal ruptures. It is fixed with fully threaded
6.5 mm cancellous bone screws on the superior aspect of the
symphysis pubis.
••
- Thickness: 3.6mm
- Width: 12 mm
- Hole spacing : 25 mm
6.11 Mini Fragment Instruments and Implants
6.11.1 Mini Fragment Instruments
The instruments used for the reduction and temporary fixation

of fragments of diminutive size, and for the application of mini
implants, are similar in design to instruments used for large and
small fragments. Their size is reduced to accommodate tiny
fragments. Handles, however, are not always proportionally
smaller since surgeons' hands remain the same size.
Great care is required in the use and handling of these delicate
instruments. The small diameters of drill bits and taps, as well as
the fine points and delicate jaws of reduction forceps, make
them susceptible to breakage if misused.
The mini fragment instruments and implants can be obtained in
either a graphic case or in a sterilising case.
Standard Instruments for 2.7 mm Implants
Drill Bit D esign (see Sect. 6.2)

This drill bit, 100 mm/75 mm (total and effective lengths), is
used to prepare the thread hole for 2.7 mm cortex screws, and
also the gliding hole for 2.0 mm cortex screws. It has a quick
coupling end to fit the small air drill. Drill bits should always be
used with a drill sleeve or guide of the same size to protect both
the drill bit and surrounding soft tissue. Drill bits must be sharp
when used.
227
•
Drill Bit, 2. 7 mm Diameter 0
This drill bit, 100 mm/75 mm (total and effective lengths), is

used to prepare the gliding hole for 2.7 mm cortex screws, when
they are used as lag screws. It has a quick coupling end to fit the
small air drill. The 2.7 mm drill bit should be used with the dou-
ble drill sleeve end, 2.7 mm to protect both the drill bit and sur-
rounding soft tissue.
Small Countersink, 2. 7 mm
This countersink is used to cut a recess in a thick cortex. This al-
lows accommodation of the screw head and distributes the pres-
sure over a greater area, when the screw is inserted as a single
lag screw. The 2.0 mm diameter tip centres the countersink in
the pre-drilled thread hole. It is used with the handle with quick
coupling. Countersinks of current manufacture have five cut-
ting edges instead of four. This increases the cutting capability.
Note: Always countersink before measuring

This gauge measures the drilling depth for 2.7 mm screws up to
60 mm. The hook must engage the opposite cortex securely be-
fore the sleeve is pushed onto the bone or the plate and the mea-
surement taken. If the drill hole is at an angle, the longest depth
must be measured. Depth gauges of recent design have a lock-
ingscrew.
Note: Always measure before tapping.
Tap Design (see Sect. 6.2).

Tap for 2. 7 mm Cortex Screws
This tap is used to pre-cut the thread in the bone before the cor-
tex screw can be inserted. The 33 mm long thread has the same
configuration as the screw thread, but only the first two conical-
ly increasing threads are cutting. The flutes extend from the tip
as far as the first ten threads only. The long threaded portion
protects the newly cut path as the tap is advanced. The tap is
~ used with quick coupling handle and the double drill sleeve end,
§. 2.7 mm. The handle is turned clockwise and anti-clockwise once
] until the tip has passed through the far cortex. This action allows
~ bone debris to be deposited in the flutes. Tapping must be done
-c by hand and not with a power machine.
=
eo:
=
.::.... Double Drill Sleeve, 2. 7 mm/2.0 mm
....eo:
= This drill sleeve has a sleeve on each end of the handle, and
e
<;J
should be used for the protection of tissues and instruments.
.......= The 2.7 mm sleeve is used with the corresponding tap and drill
.s"' bit. The 2.0 mm sleeve is used with the 2.0 mm drill bit. It may be
• 228
used through plate holes or separately, and it is steadied by
pressing the serrated end onto the bone. The 2.0 mm sleeve can
be used as an insert sleeve in lag screw technique with 2.0 mm
cortex screws. The hole in the handle adjacent to the sleeve can
be used over a previously inserted Kirschner wire (up to 1.6 mm
diameter) to permit parallel drilling. The distance of 4.5 mm be-
tween the wire and the screw allows the use of a washer.

This handle is used with the countersink, the tap, 2.7 mm, and
~ with the small hexagonal screwdriver shaft. The rotating end of
the handle permits support in the palm and precise turning of
the instrument with two fingers.
-...
Small Hexagonal Screwdriver

This screwdriver has a hexagonal tip (width across flats 2.5 mm)
which fits snugly in the hexagonal socket of the small fragment
screws allowing easy insertion and removal. The shaft has a
groove which is necessary to connect the screw-holding sleeve.
The handle is designed so that excessive force cannot be applied
when inserting the screws.
Note: Never use a screwdriver with a damaged tip. This will then
damage the socket of the screw head and make removal very
difficult.
.· Small Screw-Holding Sleeve, 2. 7 mm

This sleeve holds the screw by a self-retaining mechanism. It is
slid onto the shaft of the small hexagonal screwdriver which has
a groove to receive it. It is especially useful when removing shaft
screws, as traction can be applied. The screw-holding sleeve has
to be disassembled carefully for cleaning.

This shaft can be connected to the handle with quick coupling,
and used to insert screws, if the regular screwdriver is unavail-
able. The screwdriver shaft can also be coupled with the small
air drill and used for removal of screws, but only after they have
first been loosened by hand.
229
•
Standard Instruments for 2.0 mm and 1.5 mm Implants
Drill Bit, 2.0 mm

See under "Standard Instruments for 2.7 mm Implants"
(p. 227).

This drill bit, 85 mm/60 mm (total and effective lengths), is used
to prepare the gliding hole for the 1.5 mm cortex screw, and the
thread hole for the 2.0 mm cortex screw. It has a quick coupling
end to fit the small air drill. This fine diameter drill bit is also sus-
ceptible to breakage and must be used with great care to avoid
damage. The use of the corresponding size drill sleeve is recom-
mended.

This drill bit, 60 mm/35 mm (total and effective lengths), is used
to prepare the thread hole for the 1.5 mm cortex screw. It has a
quick coupling end for use with the small air drill. Due to its very
small diameter it must be used with great care lest it break, espe-
cially when coupled with the drill. The use of the correct size
drill sleeve helps to protect the drill bit as well as the soft tissue.
Mini Countersink, 1.5 mm/2.0 mm

The mini countersink, for the handle with mini quick coupling,
is used to cut a recess in dense cortical bone to intensifier the
screw head and to distribute the pressure over a greater area.
The 1.1 mm tip centres the countersink in the pre-drilled hole,
and the five cutting edges enable easy cutting when turned
clockwise.
Note: Countersink before measuring.

The depth gauge measures up to 38 mm. The fine and delicate
probe is protected by a screw-on sleeve, which should be re-
moved only when measuring and cleaning. The hook should en-
"'~ gage the far cortex before the sleeve is pushed onto the bone
S-
·='5 and the measurement taken.
The depth gauge must be carefully disassembled before clean-
~ in g.
-==
=
=
-e=
c
·~ Tap for 2.0 mm Cortex Screws
~
-
This tap has a 24 mm thread length, and is used to cut the thread
2 in the bone before inserting 2.0 mm cortex screws. It couples
.s"'
• 230
with the handle with mini quick coupling. The 2.0 mm double
drill sleeve end is used for protection of the tap.
Note: The tap is always used after measuring.
Tap for 1.5 mm Cortex Screws

This tap has a 20 mm thread length, and is used to cut the thread
in bone before inserting 1.5 mm cortex screws. It is used with the
handle with mini quick coupling and the 1.5 mm double drill
sleeve end for protection. As a general rule the tap is turned
twice clockwise and once anti-clockwise to allow bone debris to
collect in the flutes . The tip should pass through the far cortex
before the tap is removed.
Note: The tap is always used after measuring.

This sleeve is similar in design and function to the double drill
sleeve described above (2.7 mm/2.0 mm). It is the sleeve neces-
sary when drilling 1.5 mm or 2.0 mm, and tapping for a 2.0 mm
screw. The handle has a hole for a previously inserted Kirschner
wire (up to 1.25 mm diameter) if parallel drilling is necessary.
The distance between wire and the screw is 4.0 mm to allow the
use of a washer.
.... \ Double Drill Sleeve, 1.5 mm/1.1 mm

This sleeve has a 1.5 mm sleeve on one end of the handle and a
1.1 mm sleeve on the other end. The 1.5 mm sleeve is used with
the 1.5 mm tap and drill bit, and the 1.1 mm sleeve with the
1.1 mm drill bit, for the insertion of 1.5 mm cortex screws. The
serrated end allows secure purchase on the surface of the bone,
and the thin-walled sleeve permits exact placement of screws in
a plate hole. The hole in the handle near the sleeve allows use
over a previously inserted Kirschner wire (up to 1.25 mm diam-
-=
eter) for parallel drilling. The distance of 2.8 mm between the
wire and the screw permits the use of a washer. "'
Handle with Mini Quick Coupling -a=
....e
-
This handle is used with the mini countersink, the taps for
=
"C
1.5 mm and 2.0 mm screws, and the mini hexagonal screwdriver =

"'
shaft. The rotating end of the handle allows support in the palm =
e
-=
~
while turning the instrument using two fingers.

2
-e=
...."'
~
=
Of)
~
·=
~
231 •
Handle with Mini Quick Coupling and a Plastic Handle
This is an alternative to the handle with mini coupling described
above. The handle may be supported in the palm, while turning
the front part of the handle with two fingers.
Mini Hexagonal Screwdriver

This screwdriver, with holding sleeve, has a hexagonal tip
(1.5 mm width across the flats) to fit the stainless steel mini
screws. The removable holding sleeve grips the screw during in-
sertion, but is pushed back for the final tightening.
Mini Hexagonal Screwdriver Shaft

This screwdriver shaft, with holding sleeve, has a hexagonal tip
(1.5 mm width across the flats) to fit the stainless steel mini
screws. It can be used with the handle with mini quick coupling
instead of the regular screwdriver. The removable holding
sleeve grips the screw during insertion, but is pushed back for
the final tightening.
Cruciform Screwdriver Shaft

This screwdriver shaft is used with the handle with mini quick
coupling, for the insertion of titanium 1.5 mm and 2.0 mm cor-
tex screws that have a cruciform head slot. (In the USA it is also
used for stainless steel mini screws.) The removable holding
sleeve grips the screw during insertion, but is pushed back for
the final tightening.
General Instruments
Small Retractors, Widths 6 and 8 mm

Small retractors, 160 mm long, are used to expose fractures of
the metacarpals and the metatarsals. Excessive pressure on the
, soft tissue must not be applied.
=
~
C"'
·a
.c
Periosteal Elevator, Straight Edge, Width 3 mm
u
~ This elevator, with a slightly curved blade, is used to aid reduc-
] tion, cleaning of fracture fragments, and for preparation of
eo:
c screw and plate sites. It is not used to strip the bone widely of the
0
;: periosteum.
~
c
-
e
~
2
....~
• 232
Reduction Forceps with Points, Narrow
This forceps, 132 mm, has narrow serrated jaws and fine points
to allow for exact reduction of fractures of small bones, as in the
hand and the foot, for example. The narrow jaws do not com-
promise the soft tissue. A fine ratchet lock permits easy and
even closure.
Reduction Forceps with Points, Broad

This forceps, 132 mm, has broad serrated jaws and points and is
used in similar manner on the same bones as mentioned above,
but allows room for a plate. The forceps has a fine ratchet lock
for easy and even closure.
"Stag beetle" Forceps

This forceps, 120 mm, has jaws that resemble the antler-like
mandible of the male stag beetle. The fine points of this forceps
makes it possible to fix bone on one side either through the soft
tissues, without having to strip them aside, or even percuta-
neously. This has practical value in the phalanges. The fine
ratchet lock permits controlled closure.
Plate Cutting Forceps

This forceps, 256 mm, for 1.5 mm - 2.7 mm plates (except DCP,
2.7 mm), is used to cut the plates to the desired length and
shape. The mechanism enables clear cutting, without leaving
sharp edges, and extra trimming is not necessary.
233 •
Sharp Hook
This hook is used to inspect fracture lines, and to reduce frag-
ments. It can also be used to clean screw head sockets before re-
moval, and to free instruments with threaded parts of bone and
tissue debris.
Screw Forceps
These forceps, with a simple self-holding mechanism, are used
to remove screws from the rack.
Plate-Bending Forceps
These forceps, 140 mm, are used in pairs for precise bending or
twisting of 1.5 mm 2-7 mm plates.
Wire-Bending Pliers
These 155 mm pliers can be used to hold and bend wires. They
can also be used to cut wires up to 1.6 mm in diameter.
Small Wire Cutter

This 175 mm wire cutter for cutting cerclage and Kirschner
wires up to 1.25 mm in diameter. The oblique jaws permit cut-
ting at their very tip.
"'
~
=
=' Bending Iron, for Kirschner Wires 0.8, 1.0 • fb \. ~
]~ and 1.25 mm Diameter

~ This bending iron has been designed to permit bending of
-=eu= Kirschner wires close to the bone or skin surface.
.......eu=
0
....
=
..e=
~
--
"='
• 234
Drill Bits, 1.1,1.5, 2.0 and 2. 7 mm Diameter

These bits are also available with three flutes, in different
lengths, and also with triangular end to fit Jacobs chuck. See
SYNTHES catalogue for further details.
Taps for 1.5, 2. 0 and 2. 7 mm Screws

Taps longer than those described in Sect.6.11.1.1 are available.
The thread length of the tap should be at least as long as that of
the screw, or else the pre-cut thread in the near cortex will be
damaged by the unthreaded shaft of the tap. See SYNTHES
catalogue for details.

. ..
This guide wire can be used as a guide for the insertion ofKirsch-
nerwires. The three holes on one side allow parallel placement of
wires, which is necessary in tension band wiring technique.

This drill guide, neutral and load, is used when applying a DCP,
2.0 mm, for the placement of neutral screws (green end), and
load screws (yellow end) The 1.5 mm drill bit is used. The self-
compression distance achieved with the load screw is 0.6 mm
(arrow towards the fracture).
DCP Drill Guide, 2. 7 mm

This drill guide, neutral and load, is used when applying a DCP,
2.7 mm. The drill bit 2.0 mm is used to pre-drill for 2.7 mm cor-
tex screws either in neutral position (green end), or in load posi-
tion (yellow end). The self-compression achieved with the load
screw is 0.8 mm (arrow towards the fracture).
Holding Sleeves
-
"'c
-
-a
~
These sleeves for the mini and small screwdrivers can be ob-
tained separately, if they are lost or damaged. Seep. 232. e
-e
"C
c~
Holding Clips
"'c
These clips, marked 2.0 or 2. 7 mm, are made of implant material ~
---e
and can be used to hold plates and washers. Regular safety pins 2
cannot be used because of the risk of corrosion being transmit- "c'
ted. c
~
~
~
~
·=~
235 •
Bending Irons for Small Plates, 2. 7 and 3.5 mm, 150 mm
These bending irons have two slots with different widths to
bend plates of various thicknesses. Bending and twisting is per-
formed by placing the two irons opposite each other. The differ-
ently orientated slots allow easy overbending at the middle sec-
tion of the plate. The longitudinal slots at the end can also be
used for twisting and bending.
"Termite" Forceps
This forceps, 90 mm, is a lightweight (15 g) reduction forceps
used especially for fractures of the phalanges and small
metacarpal fragments. It has flared jaws, very fine points and a
fine ratchet lock. The fine points allow percutaneous fixation.
Because of its light weight, the forceps remains in position once
it has been locked.
Forceps with Sliding Jaws

This forceps has an angulated handle with speed lock, and jaws ----- -·~--- ----
that move parallel to each other. The upper jaw is interchange-

able; one has a point and one a foot plate. They oppose a sta-
tionary pointed hook.
The forceps is used for reduction and provisional fixation of the
third and fourth metacarpal, where access is often a problem.
The foot plate can be used to hold a mini plate against the bone.
Self-Centring Bone Holding Forceps, 150 mm

This forceps, with speed lock, has its application mainly in
metacarpal or metatarsal fractures; sometimes also in fine fore-
arm bones. The self-centringjaws make application easy even in
small wounds .
• 236
Reduction Forceps with Serrated Jaws, 140 mm
This forceps is excellent for reduction and temporary retention
of a plate, such as on the forearm, the fibula, or the metacarpal
and metatarsal bones. The ratchet is easy to handle and to close.
The forceps are also available with a speed lock.

This forceps may be used for reduction of the metatarsal and
metacarpal bones. However, its wide jaws makes it more diffi-
cult to apply, than the narrow reduction forceps described in
Sect. 6.11.1.1. The forceps are available with both ratchet and
speed-lock closure.
-=
"'
eo:
c.
....e
=
"C
-
eo:
"'=
.
Malleable Retractors, 8 and 10 mm Wide ~
·"' These retractors, 230 mm long, can be moulded to the desired

-....=~
shape.
Periosteal Elevators
-=
"'
~
~
Different sizes of these elevators are available. See SYNTHES ~
catalogue. ·=
~
237
•
Holding Forceps for Small Plates
This forceps is used to provisionally hold small plates when
planning the correct site, or while drilling.
Hammer, 100 g
This hammer is to be used with fine osteotomes for osteotomies
in, for example, the hand.
Osteotomes, 2, 5,10 mm Wide

These osteotomes, 150 mm, are used for osteotomies in the
hand.
Small Distractor
See Sect. 6.14.2
Mini Air Drill

See Sect. 6.21.3.4. See also the SYNTHES catalogue.
Mini Drill Sleeve, 1.1 and 1.5 mm

This sleeve has been replaced by double drill sleeve,
1.5 mm/1.1 mm.
Tap Sleeve, 3.5 mm

This sleeve, used as tap sleeve for the 2.7 mm tap, has been re-
placed by double drill sleeve, 2.7 mm/2.0 mm
Insert Sleeve, 2. 7 mm/2.0 mm

This sleeve is no longer necessary since its function is taken over
by the double drill sleeve, 2.7 mm/2.0 mm.
Small Hexagonal Screwdriver with Holding Sleeve

This screwdriver has been replaced by the small hexagonal
screwdriver with groove in the shaft for the screw-holding
sleeve.
• 238
Bending Pliers for Small Plates
These pliers, with one or two "warts", have been replaced with
the two small plate-bending forceps described in Sect. 6.11.2.
Holding Forceps for Finger Plates

It has been found that too extensive an incision is required for
the holding forceps for finger plates to be of practical use in the
hand.
Retractor for Small Fragments, 120 mm

This retractor, with a ring handle, has been replaced with the
160 mm long retractor, that has a 15 mm wide blade.
6.11.2 Mini Fragment Implants
Internal fixation of fractures in the hand and the foot has gained
favour in recent years. The goal of providing the stability needed
for early postoperative mobilisation in large bones also applies to
smaller bones. The same basic principles of open reduction and
stable internal fixation apply, only the size of implants varies. The
trend towards using small implants has led to the development of
a large number of different types and sizes. All the implants are
now available in titanium as well as in stainless steel.
The implants are delicate as are the instruments needed for
their application. They are designed to be handled with skill
rather than force.
6.11.2.1 The Mini Fragment Screws
The mini fragment screws, 2.7, 2.0, and 1.5 mm cortex screws,
are used as lag screws or as plate fixation screws. In small-sized
bones the cancellous bone is rather dense, allowing the use of
cortex screws also in the metaphyseal and epiphyseal areas. The
screws are available in both stainless steel and titanium.
2. 7 mm Cortex Screw
This screw is used for lag screw fixation of metacarpal and
metatarsal fractures, as well as of small fragments in the forearm
and the ankle. The 2. 7 mm cortex screw is also used for the ap-
plication of 2.7 mm plates in these bones. It can also be used
with a spiked plastic washer to reattach avulsed ligaments.
239
•
The asymmetrical, buttress thread of the screw permits excel-
lent hold in the bone. The bone has to be tapped before screw in-
sertion. The screw head has the same sized hexagonal socket as
the small fragment screws (2.5 mm), and the same core diame-
ter as that of the 4.0 mm cancellous bone screws (1.9 mm).
Therefore the same depth gauge and screwdriver is used for
2.7 mm screws as for the small fragment screws. The screw head
has a spherical undersurface.
The 2.7 mm cortex screws are available in lengths from 6 mm to
40 mm, in 2 mm increments.
- Head diameter: 5.0mm 2,5
- Hexagonal socket: 2.5mm
2,7
rr
- Core diameter: 1.9mm •
• mmm!!m @
- Thread diameter: 2.7mm
- Pitch: l.Omm 5.0
- Drill bit for gliding hole: 2.7mm f
- Drill bit for thread hole: 2.0mm 2.0
-Tap: 2.7mm
2.0 mm Cortex Screw

This screw is used for lag screw fixation of fragments in the prox-
imal and middle phalanx, in small metacarpals and in fractures
of small radial heads. It is also used for the application of2.0 mm
mini plates in these bones.
The screw has an asymmetrical buttress thread for sound pur-
chase in the bone after tapping. The screw head has a spherical
undersurface. The head of the 2.0 mm screw is available with ei-
ther a hexagonal socket (stainless steel screws), or a cruciform
recess (titanium screws, and in the USA the stainless steel
screws.). Care must be taken to have the correct screwdriver
available.
The 2.0 mm cortex screws are available in lengths from 6 mm to
38 mm, in 2 mm increments.
- Head diameter: 4.0 mm (titanium3.5 mm) 0,6 3.5-"
"' - Core diameter: 1.3 mm (titanium 1.4 mm)
g.
~
- Thread diameter: 2.0mm ®
·a..c - Pitch: 0.6mm 1.3
( 1.4 T i )
1.5
r-
~ - Drill bit for gliding hole: 2.0mm @
-c - Drill bit for thread hole: 1.5mm
=
= -Tap: 2.0mm - '"'
--==
=
.s
1.5 mm Cortex Screw
e
~
This screw is suitable for lag screw fixation of tiny fragments of
e the phalanges, the metacarpals and the radial head. It is also
.s
~
used for the application of 1.5 mm mini plates .
• 240
Considering the size of this very small screw it has excellent pur-
chase in the bone thanks to its asymmetrical buttress thread.
The bone has to be pre-tapped. The screw head has a spherical
undersurface.
The 1.5 mm cortex screw is also available with either a hexago-
nal socket head (stainless steel screws), or a cruciform recess ( ti-
tanium screws, and in the USA also the stainless steel screws).
The correct screwdriver must be selected.
The 1.5 mm cortex screw exists in lengths from 6 to 20 mm;
6-12 mm in 1 mm increments, and 14-20 mm in 2 mm incre-
ments.
1.1
j Important dimensions.
- Head diameter: 3.0mm
~ €1~ l.Omm
- Core diameter :
I@I
I
1.5
I - Thread diameter: 1.5mm
-~ 1-- - Pitch : 0.5mm
1.5 - Drill bit for gliding hole : 1.5mm
- Drill bit for thread hole: 1.1mm
-Tap: 1.5 mm
Washer, 7.0 mm Outer Diameter

This washer, available in both stainless steel and titanium, may
be used to prevent the head of the 2.7 mm screw from splitting
· the cortex and sinking into the bone.
Washer, 4.5 mm Outer Diameter

This washer may be used with 1.5 or 2.0 mm cortex screws to
prevent their heads from splitting the cortex and sinking into
the bone.
Spiked Washer, 8.0/3.2 mm Diameter

This washer is made of polyacetate and stainless-steel rein-
-=
forced for X-ray contrast. It can be used with a 2.7 mm cortex ,
screw for the reattachment of an avulsed ligament. c"'
-=
The washer is autoclavable (maximum 140 °C, or 280 °F) up to "S.
30 times. It must be left to recrystallize at least 8 h before use. e
"C
-e=
c
"'
~
..=
--
t;;
=
=
e
~
rZ=
~
·=~
241 •
6.11.2.2 Mini Fragment Standard Plates
The Standard Plates for 2.7 mm Screws
Quarter-Tubular Plates
These plates are mainly used as tension band plates in fractures
of metacarpal and metatarsal bones. The plate offers good lon-
gitudinal stability if in complete contact with the bone. This is
achieved either by the edges along the plate or by the "collars"
around the plate holes. Due to the "one-quarter of a tube"
cross-section, the screw head is almost flush with the plate sur-
face when inserted through the plate hole. As a consequence the
undersurface of the screw head protrudes through the under-
surface of the plate. If used on a bone with small circumference,
the screw head may be in contact with the bone, preventing the
plate from being securely fixed. To overcome this problem new-
er stainless steel plates have a collar around the holes on the un-
derside. These collars prevent the screw head from protruding
and secure the contact with the bone.
The plates are available in lengths from 23 mm to 63 mm, with
3 to 8 holes.
- Thickness: lmm
- Width: 7mm
- Hole spacing: 8mm
Small L Plates, 2. 7 mm Oblique

These plates are mainly used in fractures of the distal or proxi-
mal ends of the metacarpal bones. The thin plates are easily con-
toured with two bending pliers. The head is placed over the
wider metaphysis. The slightly oval holes permit eccentric
placement of screws to produce some compression.
The plates are available in left and right oblique versions, with
3 holes in the shaft and 2 in the head.
'I}
·a
~ - Thickness: 2mm
- Width: 7mm
.c
(J - Hole spacing: 8mm
~ - Length: 35mm
"CS
=
=
--
.::= Small T Plates, 2. 7 mm
= These plates are similar to the L plate in use and design, but the
= head is T-shaped rather than L-shaped.
..e=
~
-
....=
' I}
There are 3 holes in the shaft and 2 in the head.
• 242
......
- Thickness: 2mm
-Width: 7mm
- Length: 32mm
Small Condylar Plates, 2. 7 mm

These plates are designed to be used in periarticular fractures in
metacarpal and metatarsal bones. The plates have a 2.7 mm
wide and 20 mm long pin at 90 o in one end, positioned either to
the left or to the right of a coaxial plate hole. The pin is cut to the
desired length with a plate cutting forceps. The implant pro-
vides firm fixation in the fragment adjacent to the joint with
minimal space requirement. The plate is notched to allow easy
contouring.
The small condylar plates, 2.7 mm are available with 6 holes in
the shaft and 1 beside the pin. At present the plate is only manu-
factured in titanium.
- Important dimensions:
- Profile:
- Thickness:
-Width:
- Hole spacing:
See figure
1.6mm
7 mm
8 mm
The Standard Plates for 2.0 mm Screws
Straight Mini Plates, 2.0 mm

Straight mini plates, with 20 holes, can be cut to the desired
-
length with the plate-cutting forceps. The unused portion may
be used for other applications. The plate is mainly used in pha- "'c
co:!
langeal fractures. It is easily contoured with two plate-bending Q.
forceps. Some compression is possible by eccentric placement ....=
of the screws in the oval holes. -=c
-=
-
co:!
Important dimensions: "'c
- Profile: See figure Q,j
- Thickness:
- Width:
- Hole spacing:
1.2mm
5 mm
5 mm
--2
...."c'
cQ,j
- Length: 10 mm
=
E
~
·=
~
243 •
Mini T Plates, 2.0 mm
These plates are T-shaped, and can be cut to the desired length
and shape with the plate-cutting forceps. The plate is used in the
distal or proximal ends of phalanges. The head portion is placed
over the metaphysis.
Contouring is easy using two plate-bending forceps. Some com-
pression can be achieved by placing the screws eccentrically in
the oval plate holes.
The 2.0 mm mini T plate is available with 9 holes in the shaft,
and with either 3 or 4 holes in the head.
- Profile:
- Thickness:
- Width:
See figure
1.2mm
5 mm
-
- Length: 50 mm
Mini Condylar Plates, 2.0 mm

These plates are designed to be used in fractures or osteotomies
near the metacarpophalangeal (MP) or proximal interpha-
langeal (PIP) joints. At one end, the plates have a 2.0 mm wide
pin, 14 mm in length, set at 90 ° either to the left or right of a
coaxial plate hole. The pin is cut to the desired length with a
plate-cutting forceps before insertion into the metaphyseal
bone. The implant provides firm fixation in the fragment adja-
cent to the joint with minimal space requirement. The plate is
notched to allow easy contouring.
The 2.0 mm small condylar plates are available with 6 holes in
the shaft, and 1 beside the pin. The plates with the pin to the left
are available in both stainless steel and titanium, plates with the
pin to the right are available only in titanium.
- Profile:
- Thickness:
-Width:
See figure
1.2mm
5 mm
-
"'
~
=
a
·=-=
1.1
Standard Plates for 1.5 mm Screws
~
"C Straight Mini Plates, 1.5 mm
=
--=
eQ
=
.~
These plates, with 20 holes, can be cut to the desired length with
eQ the plate-cutting forceps. The remaining portion may be left for
other applications. The plate is mainly used in phalangeal frac-
..-=e
~
tures. It is easily contoured with the two plate-bending forceps.
-=
"'
Some compression is possible by placing the screws eccentrical-
ly in the oval holes.
• 244
-
- Thickness: 0.9mm
- Width: 3.8mm
- Length: 100 mm
Mini T Plates, 1.5 mm

These plates are T-shaped and can be cut to the desired length
and shape with the plate-cutting forceps. The plate is used in the
distal or proximal ends of phalanges. The head portion is placed
over the metaphysis.
Contouring is easily achieved with the two plate-bending for-
ceps. Some compression can be achieved by placing the screws
eccentrically in the oval plate holes.
The mini T plates, 1.5 mm are available with 9 holes in the shaft,
and with either 3 or 4 holes in the head.
- Profile:
- Thickness:
-Width:
See figure
0.9mm
3.8mm
- Length: 50 mm
Mini Condylar Plates, 1.5 mm

These plates are designed to be used in fractures or osteotomies
near the metacarpophalangeal (MP) or proximal interpha-
langeal (PIP) joints. At one end, the plates have a 1.5 mm wide
pin, 14 mm in length, set at 90 o either to the left or to the right of
the coaxial plate hole. The pin is cut to the desired length with a
plate-cutting forceps before insertion into the metaphyseal
bone. The implant provides firm fixation in the fragment adja-
cent to the joint with minimal space requirement. The plate is
-==
notched to allow easy contouring.
The 1.5 mm mini condylar plates exist with 6 holes in the shaft,
"'
and 1 beside the pin. The plates with the pin to the left are avail-
able in both stainless steel and titanium, plates with the pin to
the right only in titanium. -=
Q.
e
- -
=
"C
"'
=
e
Q,l
- Thickness: 0.9mm
--=
E
-=
- Width: 3.5mm
"'
- Plate length: 26 mm Q,l
~
e
roo.
·=~
245 •
Kirschner Wires
Kirschner wires in stainless steel and titanium alloy are avail-
able with a diameter of0.8 mm and a length of70 mm, with a di-
ameter of 1.0 mm and a length of 150 mm, or with a diameter of
1.25 mm and a length of 150 mm, and with a trocar tip. They are
used for reduction and temporary, or definitive fixation of frac-
tures in the hand and foot, or in other small bones.
They are inserted with either the mini air drill or the small air
drill with Jacobs chuck. The different lengths should help in
identifying the diameter of the wire. Further sizes are available.
Cerclage Wires
Cerclage wires, 0.6 mm in diameter and 175 mm long, and
0.8 mm in diameter and 200 mm long, are sometimes used for
tension band wiring of mini fragments. The wire has excellent
tensile strength and is easy to handle. The pre-cut lengths help
to identify the different diameters of wires.
6.11.2.3 Supplementary Implants
DCP,2.7mm
This plate is similar in design to its larger counterparts, DCP,
4.5 mm and 3.5 mm, and is used in mandibular and veterinary
surgery, but has also found application in metacarpal and
metatarsal fractures. The DCP drill guide, 2.7 mm, neutral
(green) and load (yellow), is used to drill for the 2.7 mm cortex
screw. Self-compression can be obtained by using the load drill
guide (arrow towards the fracture) for eccentric placement of
the screw in a plate hole. The axial displacement is 0.8 mm. To
obtain further compression, the articulated tension device can
be used. The plate is contoured with the small bending irons.
The DCP, 2.7 mm is available in lengths from 20 mm to 100 mm,
with 2 to 12 holes. The two-hole plate with longer hole spacing is
-
used in mandibular surgery.
"'~
·a -
- Thickness up to 6 holes: 2.0 mm (titanium 2.2 mm)
Thickness 7- 12 holes: 2.5 mm (titanium2.7 mm)
-5 - Width: 8 mm
~ - Hole spacing: Sand 12 mm
"C
;
--==
...=
0
Small L Plate, 2. 7 mm, Left and Right Angled
These plates are similar in design and use to the oblique L plate
(see above).
-.s=..
=
~
"'
• 246
··-· ... DCP,2.0mm
This plate is similar in design and use to the other DCPs. It is
used in the hand or the foot, especially in secondary procedures,
when an extra strong implant is required. The DCP drill guide,
2.0 mm is used to drill for the 2.0 mm screws. Axial self-com-
pression of 0.8 mm can be obtained if the load (yellow) drill
guide is used (arrow towards the fracture).
The DCP, 2.0 mm is available in lengths from 22 to 42 mm, with
4to 8 holes.
- Thickness 4-6 holes: 1 mm
- Thickness 7, 8 holes: 1.5mm
-Width: 5 mm
Straight Plate, 2.0 mm

This plate is used for diaphyseal fractures of the phalanges.
Some axial compression may be obtained by eccentric place-
ment of screws in the oval plate holes.
The plate is available in lengths from 17 mm to 35 mm, with 3 to
6holes.
- Profile:
- Thickness:
-Width:
See figure
1.2mm
5 mm
~ AdaptationPlate,2.0mm
The adaptation plate, with 20 holes, is a very thin and malleable
plate which has edge indentations between holes that allow
bending in two planes. It can be cut to the desired length with
the plate-cutting forceps. The plate may be used in the recon-
struction of fingers.
-==
-
rl:l
Important dimensions: "S..

- Profile: See figure ....e
- Thickness: 0.9mm -=
-Width:
- Hole spacing:
5 mm
5 mm -e===
rl:l
--e=
~
- Length: 100 mm
...."'
e=
~
=
~
~
·a
~
247
•
Mini T Plate, 2.0 mm, and Mini L Plates, 2.0 mm,
Oblique and Right Angled
These plates are similar in design to their 2.7 mm counterparts,
but smaller. Their main application is in fractures near joints,
where the head is fixed first in the metaphysis and its shaft in the
diaphysis. Some axial compression can be achieved with eccen-
tric placement of the screw in the first shaft hole.
The plates are available with 2 holes in the shaft and 2 in the
head.
- Thickness : lmm
- Width: 5mm
- Hole spacing: 6mm
H Plate, 2.0 mm
This plate is used mainly for reimplantation of transversely am-
putated fingers, where extensive exposure is not desirable. It is
fixed with 2.0 mm screws.
- Thickness: lmm
- Width: llmm
- Length: 12mm
- Hole spacing: 7 and6 mm
H Plate, 1.5 mm
This plate is similar in use to the 2.0 mm H plate, but fixed with
1.5 mm screws .
. Important dimensions:
- Thickness : 0.9mm
- Width: 9 mm
- Length: 8.2mm
- Hole spacing: 5 and4.2 mm
(ll
Kirschner Wires with Double Tip
Q,j
5- These wires, available with diameters of 0.6 and 0.8 mm and

] 70 mm in length, and with diameters of 1.0 mm and 1.25 mm
~ and 150 mm in length, may be useful in the fixation of pha-
"C langeal and metacarpal fractures. Further sizes are available
=
~ (see SYNTHES catalogue).
=
--
.::
~
=
e
Q,j
...-=
2
( ll
• 248
6.11.3 Fixation Techniques with Mini Fragment Implants
6.11.3.1 Fixation Techniques with Mini Fragment Screws
As with the larger screws sizes, the mini fragment screws can be
used as lag screws, separately or through a plate, or as plate fixa-
tion screws. The principles of insertion are the same as are the
principles of screw orientation (see Sect. 6.4.4).The very small
dimension of the implants and instruments demands an abso-
lutely precise insertion technique and is difficult.
2.7 mm Cortex Screw Used as a Lag Screw,

Separately or Through a Plate Hole
Lag screw fixation with 2.7 mm cortex screws is used, for exam-
ple, in spiral or oblique fractures of metacarpal or metatarsal
bones. These are cylindrical bones with a small medullary cavi-
ty. Thanks to the introduction of the double drill sleeve system,
the standard lag screw "gliding hole first" technique may also be
employed (see next page).
"Thread hole first" technique:
- After anatomical reduction and temporary fixation, the
thread hole is drilled through both cortices with the 2.0 mm
drill bit in the double drill sleeve end, 2.0 mm (Fig.l ).
- The countersink is used to cut a recess for the screw head.
(Not if a plate is used.)
to cut the thread in both fragments (Fig. 3).
249 •
- The gliding hole is drilled with great care in the near cortex,
using the 2.7 mm drill bit in the 2.7 mm double drill sleeve
end. Note: The drilling axis must be the same as that of the
thread hole to avoid any displacement (Fig.4).
- The selected 2.7 mm cortex screw is inserted with the small
hexagonal screwdriver and firmly tightened (Fig. 5).
Variation: "Gliding hole first" technique:
- Anatomical reduction and temporary fixation.
- The gliding hole is drilled in the near cortex using the 2.7 mm
drill bit in the 2. 7 mm double drill sleeve end.
- The 2.0 mm end of the double drill sleeve is carefully inserted
into the gliding hole until it abuts the far cortex. The thread
hole is drilled with the 2.0 mm drill bit (Fig. 6).
- The countersink is used to cut a recess for the screw head. If
the screw is inserted through a plate this step is omitted.
- The screw length is measured with the 2.7-4.0 mm depth
gauge.
to tap the thread hole in the far cortex.
hexagonal screwdriver and firmly tightened. Interfragmen-
tary compression is achieved.
"'<II
·a.c=
;r
(.J
~
"0
=
--=
~
.2=
~
e
<II
.s
...."'=
• 250
2.7 mm Cortex Screw Used as a Plate Fixation Screw
The 2.7 mm plates are fixed with 2.7 mm cortex screws both in
the diaphysis and the metaphysis.
positioned in the plate hole and the thread hole drilled
through both cortices.
to cut the thread hole in both cortices.
- The selected 2. 7 mm cortex screw is inserted with the small
2.0 mm Cortex Screw Used as a Lag Screw,

In spiral or oblique fractures of the phalanges, 2.0 mm cortex

screws may be used as lag screws. The insertion techniques are
similar to those described above for 2.7 mm screws; both the
"gliding hole first" and "thread hole first" techniques are used.
"Gliding hole first" technique :
- The fracture is reduced and temporarily fixed with a fine
pointed reduction forceps (Fig.1 ).
- The gliding hole is carefully drilled in the near cortex using
the 2.0 mm drill bit in the 2.0 mm double drill sleeve end
(Fig.2).
- The 1.5 mm double drill sleeve end is pushed into the gliding
hole until it abuts the far cortex. The thread hole is drilled
with the 1.5 mm drill bit (Fig. 3).
-=
"'
-
c.
~
e
-=
=
-e
~
c"'
--..==
~
'\ '\
-e=
"'
~
/ .>
..
~
Oil
'-"
·=
~
2 3
251
•
- If necessary, a recess for the screw head is cut with the mini
countersink (Fig. 4).
- The 1.5-2.0 mm depth gauge is used to determine the screw
length (Fig. 5).
"' - The 2.0 mm tap in the 2.0 mm double drill sleeve end is used
=
~
=" to cut the thread in the far cortex (Fig. 6).

'2 - The selected 2.0 mm cortex screw is inserted with the mini
'5 hexagonal screwdriver, and tightened (Fig. 7) . (For screws
~
-== with a cruciform recess the cruciform screwdriver shaft and
= handle are used.)
--=
.s=
c
e
~
-......."=='
• 252
Variation: "Thread hole first" technique:
- After reduction and temporary fixation, the thread hole is
drilled with the 1.5 mm drill bit in the double drill sleeve end,
1.5 mm through both cortices.
- Countersink, if necessary.
- The thread hole is tapped in both cortices with the 2.0 mm tap
and the 2.0 mm double drill sleeve end.
- The gliding hole is carefully drilled in the near cortex with the
2.0 mm drill bitin the 2.0 mm double drill sleeve end.
- The 2.0 mm cortex screw of appropriate length is inserted
with the mini hexagonal or cruciform screwdriver and gently
tightened (Fig. 8).
2.0 mm Cortex Screw Used as a Plate Fixation Screw
The 2.0 mm mini plates are fixed with 2.0 mm cortex screws
both in the diaphysis and the metaphysis.
- The 1.5 mm drill bitin the 1.5 mm double drill sleeve end is
- The screw length is measured with the 1.5-2.0 mm depth
gauge.
- The selected 2.0 mm cortex screw is inserted with the mini
hexagonal screwdriver or the cruciform screwdriver shaft and
handle.
Cortex Screw 1.5 mm Used as a Lag Screw,

For the fixation of very small fragments in the hand or the foot ,
the 1.5 mm cortex screw may be the implant of choice. The same
techniques as described above also apply to this very small screw.
-=
"'
~
"S.
....e
Lag screw principle: The screw thread must have purchase in "C
=
-e=
~
"'
-=..=
Step by step procedure: ~
"Gliding hole first" technique:

- The fracture is reduced and temporarily fixed with a fine
Kirschner wire or a fine pointed reduction forceps (Fig.l ). -=e
...."'
~
~
~
~
·=
~
253 •
"'g.
Q,l
- The gliding hole is drilled in the near fragment using the
'2 1.5 mm drill bit in the 1.5 mm double drill sleeve end (Fig. 2) .
.c
c.~ - The 1.1 mm double drill sleeve end is carefully inserted into
~
"CC the gliding hole until it abuts the far cortex. The 1.1 mm drill
a bit is used to drill the thread hole in the far cortex (Fig. 3).
.5:= - If necessary, a recess is cut for the screw head with the mini
E countersink (Fig. 4).
~ - The screw length is measured with the 1.5-2.0 mm depth
-§...
....."=
'
gauge (Fig. 5) .
• 254
- The 1.5 mm tap is used in the 1.5 mm double drill sleeve end
to cut the thread in the far fragment (Fig. 6).
hexagonal screwdriver, or cruciform screwdriver shaft and
handle, and the screw gently tightened (Fig. 7).
Variation: "Thread hole first" technique:
- The fracture is reduced and temporary fixed with a fine
Kirschner wire. The thread hole is drilled through both cor-
tices using the 1.1 mm drill bit in the 1.1 mm double drill
sleeve end.
- The mini countersink is used to cut a recess, if necessary.
to cut the thread in both cortices.
- The gliding hole is carefully drilled in the near cortex with the
1.5 mm drill bit in the 1.5 mm double drill sleeve end.
hexagonal screwdriver or the cruciform screwdriver shaft and
handle (Fig. 8).
255 •
Cortex Screw, 1.5 mm Used as a Plate Fixation Screw
The 1.5 mm mini plates are fixed with 1.5 mm cortex screws
both in the diaphysis and the metaphyses of the small pha-
langeal bones.
The screw length is measured with the 1.5-2.0 mm depth
gauge.
The 1.5 mm tap in the 1.5 mm double drill sleeve end is used
The selected 1.5 mm cortex screw is inserted with the mini
hexagonal screwdriver, or the cruciform screwdriver shaft
and handle, and gently tightened.
6.11.3.2 Fixation Techniques with Mini Fragment Plates
The fixation technique of an implant will depend upon the local

anatomy and the fracture type. The following examples serve
only as guidelines.
Quarter-Tubular Plate Applied as a Neutralisation Plate
The quarter-tubular plate is mainly applied as a neutralisation

plate in lag screw fixation of spiral, or oblique, fractures of the
metacarpal bones to protect against shearing and bending
forces. The technique of application follows the same principles
as for the larger one-third tubular plates.
Prerequisites:
- Lag screw fixation at an appropriate angle, beside or through
the plate.
- All screws are placed in central (neutral) position in the plate
holes.
~ Plate length:
S, - In each main fragment four or five cortices should be engaged
'2 by screws.
'5
~ Step by step procedure:
-== - The fracture is reduced. The plate site is determined, the
--=
~
=
.~
plate exactly contoured and fixed provisionally to the bone
with forceps.
~
- If the apex of the fracture is directly beneath the plate, a

e
lj,j
-
2.7 mm cortex screw is inserted as a lag screw through the
e plate (seep. 249). In other instances a separate lag screw, be-
....
~ side the plate, is inserted using the same technique .
• 256
- The drill bit 2.0 mm in the 2.0 mm double drill sleeve end is
then used to drill through both cortices for the first plate fixa-
tion screw (Fig.l).
to cut the thread hole (Fig. 3).
hexagonal screwdriver (Fig. 4).
- The second plate fixation screw is inserted in similar manner
on the opposite side of the fracture.
- Alternating from one side to the other, the remaining 2.7 mm
cortex screws are inserted (Fig. 5).
257
•
Quarter Tubular Plate Applied as a Tension Band Plate
The plate is applied as tension band plate in short oblique, or

transverse, fractures of mainly the metacarpal bones.
Prerequisites:
- The plate is applied to the tension side of the bone.
- The plate is contoured to the shape of the bone; in transverse
fractures also slightly overbent.
- Axial compression is achieved by eccentric placement of the
screws in those plate holes nearest the fracture on each side.
Plate length :
- Five to six cortices in each main fragment should be engaged
by screws.
- After reduction and provisional fixation, the contoured plate
is applied to the bone with reduction forceps.
The first screw hole is drilled through one of the plate holes
near the fracture using the 2.0 mm drill bit in the 2.0 mm dou-
ble drill sleeve end.
- The thread is cut in both cortices with the 2.7 mm tap in the
hexagonal screwdriver, but not fully tightened.
- The plate is pulled towards the fracture to place this first
screw in the eccentric position.
- In the plate hole near the fracture in the opposite fragment,
==nb=
c._.,
the second screw hole is drilled using the 2.0 mm drill bit in
the 2.0 mm double drill sleeve end. The drill hole is placed in
the eccentric position, away from the fracture.
- After measuring and tapping the second 2. 7 mm cortex screw
is inserted and tightened. The first screw is then tightened,
compressing the fracture (Fig.l). I
I
- The remaining plate screws are inserted alternating from one

side to the other using the technique described for the first
screw.
IJ
=
~
·=
~
~ 2
=;..
--=
.~
~
-=..
:I
!I
.::;
• 258
Application of the Small T and L Plates, 2.7 mm
Oblique or transverse metaphyseal fractures of metacarpal and

metatarsal bones can be fixed with small2.7 mm Tor L plates.
Prerequisites:
- Exact contouring of the plate to the bone is mandatory, espe-
cially of the head portion.
- Axial compression by the eccentric placement of one of the
shaft screws.
- If possible, a lag screw should be inserted through the plate,
after axial compression has been applied. In such a case the
plate functions as a neutralisation plate
Plate length:
- Only one length is available.
- Axial and rotational alignment is verified.
- Exact contouring of the plate, especially the head portion.
- The first plate screw is prepared in the head by drilling with
the 2.0 mm drill bit in the 2.0 mm double drill sleeve end as a
guide (Fig.l).
- The screw length is measured with the small depth gauge,
2.7 mm - 4.0 mm.
- The thread hole is tapped with the 2.7 mm tap in the 2.7 mm
}-
double drill sleeve end.
·· ..
2 · ~~ hexagonal screwdriver through the plate hole (Fig. 2).
- The axial and rotational alignment, as well as the precise fit of
the plate, is rechecked.
- Insertion of the second 2.7 mm cortex screw in the head as de-
scribed above. To avoid collision with the previous screw, the
screwdriver shaft can be inserted in its head to indicate its di-
rection. Drill for the second screw either parallel to the first
screw, or obliquely, but on a different plane.
- The correct alignment of the plate shaft is verified before
drilling for the first shaft screw. The 2.0 mm drill bit in the
2.0 mm double drill sleeve end is positioned eccentrically in -=
<ll
~
"S.
the plate hole, away from the fracture , and the thread hole
drilled. ....e
-==
to cut the tread hole in both cortices.
-~
<ll
=
e
~
- The selected 2. 7 mm cortex screw is inserted and carefully

-=e
tightened. This screw should achieve axial compression
-=
< ll
3
....
(Fig.3).
e
~
- If possible, a lag screw is inserted through the plate.
~
- The remaining shaft screws are inserted in the neutral posi- E
4 tion using the same technique as described for the first screw. ~
Final tightening of all screws (Fig. 4). ·=~

259 •
Application of the Small Condylar Plate, 2.7 mm
The small2.7 mm condylar plate can be used for the fixation of

periarticular fractures, with or without intra-articular exten-
sions of metacarpals and metatarsals.
Prerequisites:
- Placement of the pin parallel to the joint.
- Exact contouring of the plate.
- Axial compression by eccentric placement of one screw in the
plate shaft.
Plate length:
- In the plate shaft, screws should engage four to five cortices in
oblique fractures, and five or six in transverse fractures.
- The technique of application is similar to that of the 2.0 mm
condylar plate, except that the 2.7 mm instrumentation is
used (see below).
DCP, 2.7 mm Applied as a Self-Compression Plate
The DCP 2.7 mm may be inserted as a self-compression plate

for axial compression in short oblique, or transverse, fractures
of metacarpals and metatarsals. The 2.7 mm cortex screws are
used for the fixation of the plate.
Prerequisites:
- The plate is contoured to the bone; in transverse fractures
also slightly overbent.
- Axial compression by one or more load screws.
- Stability is augmented if a lag screw can be inserted through
the plate.
Plate length:
- In each main fragment four to five cortices should be engaged
by screws.
- The fracture is reduced. The contoured plate is applied to the
bone with the middle portion placed over the fracture and
held with reduction forceps.
- In the plate hole adjacent to the fracture the first screw hole is
drilled using the 2.0 mm drill bit and the DCP drill guide,
2.7mm.
- Tapping with the tap for 2.7 mm cortex screw in the 2.7 mm
double drill sleeve end.
- The selected 2. 7 mm cortex screw is inserted with the small
hexagonal screwdriver, but not completely tightened.
• 260
- The plate is pulled towards the fracture to place the first screw
in eccentric position.
- The second screw hole is prepared in the opposite fragment in
the plate hole adjacent to the fracture. The load (yellow)
DCP drill guide is placed in the plate hole with the arrow
pointing towards the fracture and the hole drilled with the
2.0 mm drill bit.
- The thread is cut with the tap for 2.7 mm cortex screw in the
- Insertion of the 2. 7 mm cortex screw with the small hexagonal
screwdriver. Tightening of both screws produces axial com-
pression.
- If the compression is sufficient, the remaining screws are in-
serted in the neutral position, alternating from one side of the
fracture to the other: drill bit 2.0 mm in the neutral DCP drill
guide, measure, tap and insert the screw.
- A third load screw can be inserted if necessary:
- In the second plate hole the 2.7 mm load (yellow) DCP drill
guide is positioned with the arrow towards the fracture. The
hole is drilled with the 2.0 mm drill bit.
- The tap for 2.7 mm cortex screw in the 2.7 mm double drill
sleeve end is used to cut the thread.
- The chosen 2.7 mm cortex screw is inserted until the screw
head reaches the plate hole.
- Before this screw is tightened completely, the adjacent screw
must be loosened to allow further compression. After tighten-
ing of the third load screw the other screw can be retightened.
Straight Mini Plate, 2.0 mm,

Applied as a Self-Compression Plate
Straight mini plates are applied for axial compression in short

oblique, or transverse, diaphyseal fractures of the phalanges.
The plate is cut to the desired length with the plate-cutting for-
ceps and fixed to the bone with 2.0 mm cortex screws.
Prerequisites:
- Contouring of the plate with two plate-bending forceps.
- Axial compression by inserting screws in the eccentric posi-
tion.
Plate length:
- In each main fragment four cortices should be engaged by
screws.
261 •
- The fracture is reduced , and the contoured plate provisional-
ly fixed.
- In a plate hole near the fracture in one main fragment, the
1.5 mm drill bit in the 1.5 mm double drill sleeve end is used to
drill the thread hole (Fig.l).
~ - The length is measured with the 1.5-2.0 mm depth gauge
=
.S' (Fig. 2).
=
-5 - The 2.0 mm tap in the 2.0 mm double drill sleeve is used to cut
~ the thread hole (Fig. 3).
"C
=
--=
~
hexagonal (or cruciform) screwdriver but not completely
.~ tightened (Fig.4).
~
= - The plate is pulled towards the opposite fragment placing the

e
~
screw in the eccentric position.
-....e
~
• 262
(
- Through the plate hole nearest the fracture in the opposite

fragment, the second screw hole is drilled using the 2.0 mm
drill bit and sleeve placed away from the fracture (Fig. 5).
- After measuring and tapping, the second 2.0 mm cortex
screw is inserted. When both screws are tightened axial com-
pression is achieved.
- The remaining screws are inserted alternating from one side
of the fracture to the other (Fig. 6).
Application of the Mini T Plate, 2.0 mm
The mini T plate is applied in metaphyseal fractures of the pha-

langes or metacarpals. The plate is trimmed and cut to length
with the plate-cutting forceps. The 2.0 mm cortex screws are
used to fix the plate.
Prerequisites:
- Exact contouring of the plate to the bone, especially the head
portion.
- Axial compression in the head or the shaft portion by eccen-
tric placement of the screws.
Plate length:
- Four cortices should be engaged by screws in the plate shaft.
- The technique of application is similar to that of the 2.7 mm T
and L plates, except that the 2.0 mm instrumentation is used
(see above).
263 •
Application of the Mini Condylar Plate, 2.0 mm
The plate is used in periarticular fractures at the metacarpopha-

langeal (MP) and proximal interphalangeal (PIP) joints, includ-
ing fractures with intra-articular extensions. The 2.0 mm cortex
screws are used for fixation.
Prerequisites:
- Placement of the condylar pin parallel to the joint.
- Exact contouring of the plate.
- Axial compression by eccentric placement of one screw in the
plate shaft.
Plate length:
- In the plate shaft four or five cortices should be engaged by
screws.
Step by step procedure: /
- The fracture is reduced.
- A Kirschner wire is inserted parallel to the joint.
- The 2.0 mm double drill sleeve end is passed with its hole over
the Kirschner wire. The 2.0 mm drill bit is then used to drill
for the condylar pin, parallel to the Kirschner wire (Fig. 1).
- The length is measured and the pin trimmed to this length
with the plate-cutting or large wire cutting forceps. The plate
shaft length is also determined, and exactly contoured to the
anatomically reduced fracture.
- The plate hole alongside the pin is passed over the Kirschner
wire and the condylar pin inserted into the pre-drilled hole.
The Kirschner wire is then removed.
- In its place a thread hole is drilled using the 1.5 mm drill bit in
the 1.5 mm double drill sleeve end.
- The length is measured, and the thread cut using the 2.0 mm
tap in the 2.0 mm double drill sleeve end. The chosen 2.0 mm
cortex screw is inserted.
- Axial and rotational alignment is verified before the final po- I
sition of the plate shaft is determined.
- In the plate hole in the opposite fragment nearest the fracture
the 2.0 mm drill bit in the 2.0 mm double drill sleeve end is
used to drill the thread hole through both cortices (Fig. 2).
~ - The length is measured (Fig. 3).
6- - The thread is cut with the tap, 2.0 mm in the 2.0 mm double
] drill sleeve end (Fig. 4).
~ - The 2.0 mm cortex screw is inserted with the small hexagonal
-= screwdriver and tightened. Axial compression is achieved
§ (Fig.5).
=
-e
0 - The remaining 2.0 mm cortex screws are inserted one by one
~ in the neutral position after drilling 1.5 mm, measuring, and
=Cl.l tapping (Fig. 6).
-.s..=
"'
• 264
/
-==
DCP, 2.0 mm Applied as a Self-Compression Plate
The DCP, 2.0 mm may be used for axial compression in short

"'
oblique or transverse fractures in the metacarpals and meta-
tarsals. The 2.0 mm cortex screws are used for fixation. -==
"S.
e
-=e
"C
Prerequisites:
- Pre bending of the plate.
"'
--=e
~
- Axial compression by the insertion of load screws.

Plate length:
- In each main fragment four cortices should be engaged.
-e=
"'
~
- The technique of application is similar to that of the DCP,

2.7 mm, except that the 2.0 mm instrumentation is used (see
£
above).
·=~
265
•
Mini H Plate, 2.0 mm Applied as a Compression Plate
The mini H plate may be used for compression of transverse

fractures of the phalanges, or for y-shaped metaphyseal frac-
tures, when extensive exposure is undesirable. The 2.0 mm cor-
tex screws are used for fixation.
Prerequisites:
- Contouring of the plate.
- Compression by eccentric placement of screws.
Plate length:
- The plate is available only with four holes.
Step by step procedure (for example, for a transverse fracture):
- The fracture is reduced, and axial and rotational alignment
verified.
used to drill the first screw hole.
- The length is measured with the 1.5-2.0 mm depth gauge.
to cut the thread.
- The first 2.0 mm cortex screw is inserted with the mini hexag-
onal (or cruciform) screwdriver.
- The second screw in the same fragment is inserted in similar
manner.
l ·~· · ~·
I 0~
l
I
'
1
- In the opposite fragment the 1.5 mm drill bit and the 1.5 mm A B C D
double drill sleeve end are positioned eccentrically in the
plate hole, away from the fracture, and the thread hole
drilled.
- After measuring and tapping, the third 2.0 mm cortex screw is
inserted.
- The fourth screw is also inserted in an eccentric position using
the same technique. Collision with the third screw, owing to
convexity of the bone, should be avoided by placing a screw-
driver shaft in its head to indicate its direction.
Application of Mini Plates, 1.5 mm

'll
~
.~ The 1.5 mm mini plates are used for the same indications as the
..2 2.0 mm mini plates only in smaller bones. Since the shapes of the
~ plates are identical, the technique of application is similar, ex-
:! cept that the 1.5 mm instrumentation is used instead.
.a-
;
]
~
-...3
.....d
• 266
of Mini Fragment Implants
Instruments for insertion of 2.7 mm screws
IJ
..
Instruments for application of 2.7 mm plates, for D CP, 2.7 mm

below to the right
~
II I
-=
c.
"'
~
e
....
-
"C
=~
"'
=
e
-=..=
~
-e=
...."'
I
~
..
0!1
~
'"-"
·a
~
267
•
Instruments for insertion of2.0 mm screws
ll
Instruments for application of2.0 mm plates
..
b
• 268
Instruments for insertion of 1.5 mm screws
Instruments for application of 1.5 mm plates
I•
ll
~
-=
~
il
"'
--=e=
~
"S.
-e
~
"'
=
--=..=
~
-=e
"'
~
0(1
~
~
·a
~
269
•
Instruments for removal of 2. 7 mm implants
Instruments for removal of 2.0 mm and 1.5 mm implants
• 270
6.12 Intramedullary Nailing Instruments
and Implants
Intramedullary nails of various different designs have been used

for the stabilisation of long bone fractures since their introduc-
tion by Kiintscher in the late 1930s. In the early 1950s, he also in-
troduced reaming of the medullary cavity, and, around the same
time, the concept of interlocking.
AO adopted the nailing concept and developed femoral and tib-
ial nailing systems which were used for many years and finally
led to the introduction of the present AO/ASIF universal nail-
ing system, which can be used with or without locking. This sys-
tem has now been supplemented with the unreamed solid tibial
nail with locking possibilities. Intramedullary nails of earlier de-
sign, thin-walled and partially slotted, are still in use, but will not
be discussed in this book (for details, see the previous edition).
The medullary nail is a load-sharing device, much stronger than
a plate. It can thus permit an early return toweight-bearing,ifax-
ial and rotational stability is ensured. Depending on the fracture
pattern, this can be achieved by different means. The AO/ ASIF
universal nail may be used after reaming of the cavity in trans-
verse or short oblique fractures with cortical stability in the mid-
dle third of femur or tibia. Open or "closed" nailing is possible.
Interlocking is employed if the fracture is axially and/or rota-
tionally unstable, e. g. long spiral fractures, multifragmentary or
segmental fractures , or fractures of the proximal and distal ends
of the diaphysis. Reaming is then limited to a minimum.
The AO/ASIF unreamed tibial nail (UTN), which was intro-
60% duced more recently, finds its (locked) application in fresh frac-
tures of the diaphysis with severe soft tissue injuries. An on-
reamed femoral nail is currently under development.
Indications for Universal Nailing of Femur and Tibia,

With and Without Locking
Conventional nailing without locking for stable fractures with

bony support in the middle third of the bone, such as:
- Transverse fractures
- Short oblique fractures
- Delayed union or nonunion
Locked medullary nailing for unstable fractures without bony
60 o;.
33 o;. support in approximately the middle 60% of the bone, where
axial and rotational stability has to be achieved, such as:
- Fractures near the metaphysis
- Long torsional fractures
- Segmental fractures
- Multifragmentary fractures
- Fractures with bone defects
271 •
6.12.1 Standard Instruments for Universal Nailing
The instruments necessary for the insertion of the universal

femoral and tibial nails can be obtained either in graphic cases
or in sterilising trays.
6.12.1.1 Reaming Instruments
Centring Pin, 4 mm Diameter, 400 mm

This pin is introduced about 50 mm into the medullary canal at
the point of insertion and at the correct angle to guide the can-
nulated cutter. The universal chuck is used for insertion.
Cannulated Cutter, 11 mm Diameter, 350 mm

This cutter is used with the centring pin to open the medullary
canal for both femoral and tibial nailing. The centring pin can be
locked to the cutter with the Allen screw. The cannulated cutter
has a special sharpened tip to allow cutting/carving while rotat-
ing the instrument by hand. It should be rotated 180 °, and then
~ turned back. Some older instruments had a metal plate at the
& end of the handle, inviting use of the hammer, but this is not rec-
·a
-5 ommended, since damage to the delicate cutting edge may re-
~ suit. The cutting edge may be resharpened.
"'CI
=
-=
~
Large Hexagonal Allen Key
=
·=$! This key is used to tighten the Allen screw on the cannulated
cutter (see above).
..-=e
Q,j
..=
"'
• 272
This handle is used to insert the centring pin, and also the ream-
ing rod, into the medullary canal.
Small Awl
This awl may be used to open the medullary canal of both femur
and tibia by twisting movements. Great care must be taken not
to slip off the bone and damage soft tissue, or to split the cortex.
Since the introduction of the cannulated cutter, the use of the
small awl has decreased.
Hand Reamers, 6 mm, 7 mm, and 8 mm Diameter

These hand reamers can be used to broach the medullary canal
if it is obstructed by pseudarthrosis or callus. Further sizes are
available. See SYNTHES catalogue for details.
Reaming Rod, 3 mm Diameter, 950 mm

This rod, with an offset ball tip and slightly curved, is introduced
into the medullary canal and used as a guide when reaming is
performed with the flexible shafts. The ball, offset 2 em from the
tip, prevents the flexible shaft from reaming past the rod. It is
also used when removing a jammed reamer. The curved tip fa-
cilitates passage of the reaming rod through the fragments, es-
pecially in closed nailing. The proximal end of the of the rod has
two flats to accommodate the holding forceps (or the holder).
The 950 mm long rod is used to ensure that the proximal end
protrudes and can be held while reaming with the flexible shafts
with reaming depth up to 440 mm.
-=
Note: The reaming rod must be checked for damage. Proper
passage of the reamer heads and flexible shafts may otherwise
"'
be impossible and force the rod forwards into the joint.
-a
I:'J
Holding Forceps ....e

-==
This forceps holds the reaming rod in place during the reaming
process. It is attached at the proximal end while reaming, and -I:'J
"'=
e
-=
~
where the reaming rod enters the medullary canal when reamer
heads and flexible shafts are exchanged.
2
"....'
='l
:5
·;
z
="
.!
-=
..-e
~
I:'J
....=
273 •
Flexible Shaft with Front Cutting Reamer, 9 mm Diameter
This shaft has the reamer fixed to it. It is the first to be used when
reaming the medullary canal. It cuts at the front, and is stopped
only by the offset ball tip of the reaming rod, which, therefore,
must always be used with this instrument.
Note: All three flexible shafts are connected to the universal air
machine with the right -angle drive for reaming.
Note: The flexible shafts are made of three coaxially arranged
coils with soldered end pieces. This ensures great flexibility and
easy use, but makes them difficult to clean. See Sect. 6.22.5.2.
Never pull on the shaft since this could damage the coil or the
soldered connections.
Never drive the shafts in reverse, or they will uncoil!
Flexible Shaft, 8 mm Diameter, Reaming Depth up to 440 mm

This shaft is used to continue the reaming process with the sepa- I__.
rate reamers 9.5-12.5 mm (engraved on the end piece) m

0.5 mm increments. It must be used with the reaming rod.
Flexible Shaft, 10 mm Diameter, Reaming Depth up to 440 mm

This shaft is used with reamers 13.0-19.0 mm (engraved on the
end piece), also in 0.5 mm increments, in the same manner as
the above.
Medullary Reamers, 9.5-19.5 mm Diameter

These reamers are used with the 8 mm and 10 mm flexible
shafts for reaming the medullary canal. The reamers are insert-
]
ed from the side onto the dovetail end of the flexible shaft, and
held in place with two fingers until slid over the reaming rod. ww~
The conically shaped corners and the sides of the reamers are
cutting. These must be constantly checked for damage, or else ~ II illi'
W
[i use may lead to heat necroses of the inner cortex. Due to the
& time and cost involved, they cannot be resharpened but must be
] replaced when damaged (see Sect. 6.22.5.2).
C.l
~
"C
=
--=
=
~
·=
~
.-e
Q,j
=
.5"'
• 274
Tissue Protector
The tissue protector protects the soft tissue from being injured
during the reaming process. The tissue protector is held be-
tween the soft tissue and the flexible shaft at the entry point.
Medullary Tube
This tube is inserted over the reaming rod and holds the reduced
fragments in place when exchanging the reaming rod for the
guide rod. It has a marker at the tip for X-ray control. The plas-
tic tube is autoclavable, but has to be checked for elasticity, since
frequent sterilisation makes the tube brittle.
Locking Pliers
These pliers are useful if a jammed reamer has to be removed.
After uncoupling the air machine and sliding the ram over the
reaming rod, the rod is gripped at the end with the locking pliers.
By striking the ram against the pliers, the reamer should disen-
gage. The pliers may also be used to grip the nail end to loosen a
jammed conical bolt.
Air Jet, for Cleaning Instruments

This air jet, made of a non-autoclavable plastic, is used together
with the air tube to clean the flexible shafts. It can be connected
...."'
to a compressed air source, or to a water tap via a quick coupling
=
=..5
~
--==
hose.
Air Tube, 2.0 mm Diameter, for Air Jet

~
...."'
This tube is connected to the air jet by removing the nozzle
head. After inserting the tube into the head it is screwed back
=~
5
....=
-
into the nozzle. ...
"'=
l:ltl
:5
·;
'Z
~
"
-==
s
~
-
.......
~
=
275 •
6.12.1.2 Insertion Instruments
Guide Rod, 3 mm Diameter, 950 mm, with Flattened Ends,

for Tibial Nails
This rod is exchanged with the reaming rod, using the medullary
tube, before inserting the universal tibial nail. It is more flexible
than the 4 mm guide rod and can therefore "guide" the curved
tibial nail. The flattened ends prevent the guide rod from being
used as a reaming rod. The flattened distal end also allows re-
moval from the nail without getting the rod stuck in the slot of
the nail. The guide rod has two flats at the end for the holding
forceps (or for the old style holder).
Guide Rod, 4 mm Diameter, 950 mm

This rod is used to "guide" the femoral nail during insertion.
First the medullary tube is slid over the reaming rod, which can
then be removed without loss of reduction. The guide rod is in-
serted and the medullary tube removed. The guide rod has two
flats at the proximal end for the holding forceps or the holder.
Measuring Gauge for Nail Diameter

This gauge is used to check diameters of nails and reamers. For
correct measurement, the nail must be slid in as far as its middle.
Insertion Handles for Universal Femoral Nails,

9-12 mm, 13-16 mm, 17-19 mm Diameter
These handles are used for the insertion of nails within the size
"' range marked on the instrument. It is used together with the
=
~
C"'
corresponding size threaded conical bolt and locking nut. The
·a
.c
lugs on the handle must engage the positioning notches at the
(j upper end of the nail for insertion in either the left or the right
~
't:l leg (see marking). The handle is also used for proximal locking
i of the nail. The holes in the handle position the locking instru-
§ ments. See Sect. 6.12.5.3.
;
~
e
=
~
....2
-= "'
• 276
Threaded Conical Bolts for Universal Femoral Nails,
9-12 mm, 13-16 mm, 17-19 mm Diameter
These bolts are screwed by hand into the nail within the size
range marked on the bolt, and then assembled with the insertion
handle. Once the lugs of the handle have engaged the notches,
firm tightening is achieved with the cannulated socket, or com-
bination wrench. The grooves of the bolt collect any ingrown tis-
sue when removal is performed.
Note: The threaded conical bolt can only be removed from the
universal nail when the handle is positioned with the lugs in the
notches of the nail. See Sect. 6.12.6.6.
Locking Nuts for Universal Femoral Nails,

9- 12 mm, 13- 16 mm, 17- 19 mm Diameter
These nuts are screwed onto the bolt of corresponding size (see
engravings on bolts and nuts). They lock the handles in position
in the nail with the lugs engaging the notches. Firm tightening is
performed with the pin wrench.
Note: Some earlier handles, bolts and locking nuts for the uni-
versal femoral nail were marked 9- 12,12- 16, and 16- 19. This no
longer applies.
Insertion Handle for Universal Tibial Nails,

10- 14 mm Diameter
This handle is used for insertion and for locking of universal tib-
ial nails. Its lugs have to engage in the notches of the nail for in-
sertion either in the left or in the right leg (see engravings). The
-==
handle is also used for proximal locking of the nail, for which it
has to be placed on the medial side. The three holes in the han- "'
dle position the locking instruments for static or dynamic lock-
--==e=
Q.
ing (see engravings).
Threaded Conical Bolt for Universal Tibial Nails,

-=e
"'
--=
~
10- 14 mm Diameter 2
This bolt is pushed through the handle and screwed into the nail "'
e ll
end for insertion. It is tightened with the cannulated socket :S
·;
wrench, or the combination wrench. The grooves of the conical
z
"
threaded end collect any ingrown tissue when the nail is re-
moved. ~
=
-=
--==
s
~
...
277 •
Locking Nut for Universal Tibial Nails, 10-14 mm Diameter
This nut is screwed onto the bolt and locks the insertion handle
for universal tibial nails in position in the nail. The lugs of the
handle sleeve must engage the notches in the nail end. The holes
in the side are used to tighten or loosen the locking nut with the
pin wrench.
Pin Wrench
This wrench is used to tighten the locking nuts on the threaded
conical bolts. It can also be used to tighten and loosen the driv-
ing head from the curved driving piece, and to loosen the ram
guide from the threaded conical bolts after insertion.
Cannulated Socket Wrench, 11 mm

This wrench is used to tighten or loosen instruments with a sock-
et 11 mm in width.
This wrench is used to tighten or loosen instruments with a nut
11 mm width across flats. The open end can be used if already
assembled instruments have to be retightened or loosened.
Curved Driving Piece

This piece can be used together with the driving head for inser-
tion of the universal nails with a hammer. It is screwed onto the
threaded conical bolt, leaving a 3 mm gap between the rear
threads of the bolt and the striker receptacle of the curved driv-
ing piece. This distance is necessary to reduce the risk of damage
to the initial threads by hammer blows when driving in the nail.
The instrument is disassembled for cleaning.
"'
=
~
=-
·a.c
~
~
't:l
; Driving Head
-=
.~
.a
=
E
This driving head is screwed onto the proximal end of the
curved driving piece for insertion of universal nails with a ham-
mer. The hole in the neck allows insertion of the pin wrench, or
.-
2 similar instrument, to unscrew a tight driving head.
5
• 278
Ram Guide
This piece is used for insertion and extraction of universal nails
with the ram. It is hollow to allow passage of the guide rod dur-
ing insertion. The hole in the distal end is used to unscrew a tight
ram guide with the pin wrench, or similar instrument. The
threaded proximal end accepts the flexible grip.
Guide Rod Retainer

This retainer is used to prevent the guide rod from backing out
during insertion of the nail.
Ram
This ram, 1300 gin weight, is slid over the ram guide and used to
insert universal nails. By simply letting it fall a short distance,
the nail is inserted 5-10 mm at a time. The ram is also used for
the removal of nails.
Flexible Grip
This grip is screwed onto the proximal end of the ram guide to
protect the ram from disengaging during insertion. When ex-
tracting the nail the flexible grip is necessary to receive the
blows of the ram.
6.12.1.3 LockingInstruments
Drill Bit, 4.0 mm Diameter, Shaft4.5 mm, Two-Fluted

This bit, 225 mm/75 mm (total length/effective length), has a
quick coupling end. It is used to drill the pilot hole for the
4.9 mm diameter locking bolts. The 4.5 mm shaft ensures accu-
rate guidance of the drill bit in the 8.0 mm/4.5 mm protection
sleeve. A three-fluted drill bit with depth markings from 25-
100 mm, in 5 mm increments, has recently been introduced.
This drill bit allows determination of the screw length, but only
if used with the 8.0 mm/4.5 mm protection sleeve.
279 •
This 145 mm/120 mm bit for quick coupling, may be used to
drill the :1ear cortex for the 4.9 mm locking bolt if the distal
aiming device assembly is used. Thanks to its short length, it
allows drilling if the distance between the bone and the image
intensifier head does not, for some reason, permit the use of
the longer 4.0 mm/4.5 mm drill bit. It is a regular two-fluted
drill bit.

This 225 mm/200 mm bit for quick coupling is used to drill the
far cortex if the technique mentioned for the 4.5 mm drill bit is
employed. The two-fluted drill bit is then guided by the 4.5 mm/
3.2 mm insert drill sleeve.
Distal Aiming Device

This aiming device can be used to position accurately the instru-
ments ne~ded for distal locking of the universal nails, if an im-
age intensifier is used. The X-ray source must be placed under-
neath the leg and the receiver head above. It connects with the
direction finder, which is held in place by a ball bearing. The
11 mm sleeve accepts the 11 mm/8 mm protection sleeve, the
aiming trocar, and the fixation bolts. The depth gauge and the
screwdriver are also used through the sleeve. Its two sharp
points can be anchored in the bone with light taps from a ham-
mer. See also technique described in Sect. 6.12.5.3.
Direction Finder
This direction finder is connected to the distal aiming device for
the locking procedure. It has a round radiolucent circle with a
central radio-opaque dot, and two metal rings. With the dot cen-
tred in the two concentric circles, the direction finder's axis is
parallel to the image intensifier's beam. It automatically cor-
"' rects for the 4 o divergence of the X-ray beams. The second hole
g.
~
accepts the drill sleeve, 8 mm/4.5 mm, which is the same dis-
·a tance from the axis of the distal aiming device as the distance be-
-5 tween the two locking holes in the nail. The direction finder is
~
"CC made of a heat-resistant (thermosetting) plastic.
=
--=
~
=
·=
~
-=
~
5
2
"....'
• 280
Aiming Trocar
The trocar is used through the distal aiming device sleeve to cen-
tre the trocar exactly in the locking hole with the help of the
built-in metal dot. When centred, the position of the distal aim-
ing device is correct in the long axis.
Protection Sleeve, 11 mm/8 mm Diameter

The protection sleeve is inserted through either the distal aim-
ing device sleeve, or the direction finder, to guide the different
instruments used for distal locking. It is also used for the same
purpose for proximal locking through the insertion handle.
Trocar, 8.0 mm Diameter

This trocar is used with the 11 mm/8 mm protection sleeve for
insertion through the soft tissue.
Drill Sleeve, 8 mm/4.5 mm Diameter

This drill sleeve accepts the 4.0 mm/4.5 mm and the 4.5 mm drill
bits.
Insert Drill Sleeve, 4.5 mm/3.2 mm Diameter

This drill sleeve is used to guide the 3.2 mm drill bit when the far
cortex is drilled.
Depth Gauge for Locking Bolts

This depth gauge measures up to 115 mm. It has a long neck al-
lowing measuring for the locking bolt through the distal aiming
device and the insertion handle. It must be disassembled for
cleaning.
-=-==
[IJ
-e==
-e=
"CC
[IJ
Femoral Fixation Bolt
--..==
~
This bolt is used to hold the distal aiming device in position in

the first drill hole while drilling for the second locking bolt for [ IJ
the universal femoral nail. It has a long threaded portion. l ;ll

;5
Tibial Fixation Bolt
·;
This bolt is inserted through the distal aiming device to hold it in .....
'Z
.!
position in the first drill hole while drilling for the second lock-
=e
"CC
-..=
ing bolt for the universal tibial nail. It has a shorter thread than ~
-
the femoral fixation bolt.
=
281
•
Large Hexagonal Screwdriver
The large hexagonal screwdriver is needed for the insertion of
the 4.9 mm locking bolts. It is also used to lock the direction
finder in the correct position on the distal aiming device when
drilling for the second locking bolt.

This is a self-retaining screw-holding sleeve necessary to grip
and pull locking bolts when they are removed. It consists of
three parts and must be disassembled for cleaning.
Radiation Shield
This shield, 400 mm/600 mm, is made of double-layered lead
foil covered with natural rubber. The equivalent lead thickness
is 0.25 mm. The radiation shield is used to protect the surgeons
hands while drilling for the locking bolts under image intensifi-
cation. The shield is placed on the patient's leg outside the X-ray
screen to prevent scattering of rays between the surgeons hands
and the X-ray source. The shield may be sterilised in steam au-
toclaves at 134 o C (or approximately 280 o F).
Holder
The holder can be clipped onto the reaming rod and used as a
handle in stead of the holding forceps when inserting the rod
into the medullary canal. It also has a hexagonal projection at
one end which can be used instead of a screwdriver, for example
when fitting the old-style right-angle drive onto the universal air
machine.
Guide Handle for Nails

This guide handle is employed only if earlier, thin-walled and
partially slotted medullary nails are used. It is fixed to the pro xi-
~ mal end of the nail, its two lugs fitting into the nail slots, and
S. used as an anti-rotational guide while the nail is inserted.
·a
-=
(.J
Connector for Extraction Hooks
~
-==
~
This connector is screwed into the extraction hook and connect-
=
--=
ed with the ram guide, ram, and flexible grip for extraction of
.~
~
universal femoral nails, if the standard technique has failed, or if
the thread of the proximal end is damaged.
e
Q,l
-
-
:I
...
~
• 282
Extraction Hooks, 480 mm,for Nails 9-11 mm, 11-14 mm,
and 14 mm and Larger
These hooks may have to be employed if the standard technique
for femoral nail extraction has failed. It is assembled with the
connector for extraction hooks, the ram guide, ram and flexible
grip, and pushed into the nail. Once hooked onto the nail end,
extraction is performed by striking the ram onto the flexible
grip.
Radiolucent Drive
This drive allows drilling under image intensifier control, with-
out exposing the hands to high doses of radiation. It is made of
radiolucent synthetic material, and enables safe, effective aim-
ing and drilling without the need for aiming devices. It attaches
to the small air drill and is used with special drill bits (see below)
to drill for the locking bolts for both the universal and the un-
reamed nailing system.
The drill bit is inserted by pushing the quick coupling of the ra-
diolucent drive forward and inserting the plastic coupling end of
the drill bit. The drill bit is turned in order to seat the end com-
pletely, then the coupling is pulled back into its locked position.
To detach the drill bit the reversed procedure is used.
The radiolucent drive can be autoclaved to a maximum of
134 o C (290 o F). After sterilisation the drive must be allowed to
cool to room temperature, since using the drive whilst hot or
warm will result in jamming. The cooling process should not be
accelerated as this will cool the casing but not the gears within.
"" See also Sect. 6.22 for care and maintenance.
Drill Bits 4.0 mm and 3.2 mm Diameter with Coupling

for Radiolucent Drive, Three-Fluted
These bits minimise the tendency to slip off the bone surface.
-=
"'
~
-=
Q.
The short spiral portion reduces the likelihood of soft tissue 5
spooling, eliminating the need for a drill sleeve. Two sizes of
-=
"C
drill bit are used for the nailing systems : ~
Drill bit, 4.0 mm diameter, 150 mm/120 mm (effective and to- "'
--=e
~
tal length) for the 4.9 mm locking bolts (universal femoral 5
and tibial nails),
- Drill bit, 3.2 mm diameter, 150 mm/120 mm (effective and to- "'
tal length) for the 3.9 mm locking bolts (UTN). ~
:5
·;
Further sizes are available: see SYNTHES catalogue for details. z
t'
..$
Other Items '3
"C
--..=
Other necessary items include the universal air drill, the right- ~
5
angle drive and the small air drill ; see Sect. 6.2l.Regarding the ~
distractor for reduction see Sect. 6.14.
283
•
The large awl has been replaced by the cannulated cutter. The
reaming rod with olive tip, 950 mm, has been replaced by the
reaming rod with offset ball tip.
6.12.4 Universal Femoral and Tibial Nails,

and Locking Bolts
Universal Femoral Nail

This nail, introduced in 1987, is a tube with a cloverleaf cross-sec-
tion and 1.2 mm wall thickness. It has a continuous longitudinal
slot on its anterior aspect. The nail has thus a certain flexibility
under bending and torsion, and provides the necessary strength
under functional stress. The complete longitudinal slot prevents
stress concentration, particularly under torsion, and promotes
an even distribution of stress over the length of the nail.
The proximal end has an internal thread which allows use of the
threaded conical bolt for insertion and extraction of the nail.
This rigid connection between nail and the instruments used for
insertion and extraction ensures an accurate and efficient trans-
mission of forces.
The slightly flared proximal end of the nail has two notches to
receive the lugs of the insertion handle positioning it for inser-
tion in either the left or the right leg. The keystone configura-
tion of the slot in the proximal cylindrical section of the nail pre-
vents spreading of the nail end when tightening the threaded
conical bolt. For proximal locking, two holes are available: a
5 mm diameter round hole for static locking, and a second slot-
ted hole for dynamic locking. The curvature of the nail corre-
sponds to an average anatomical curvature of the adult femur of
1.5 m radius.
The distal end of the nail is rounded to allow smooth insertion
over the guide rod. For distal locking, the femoral nail has two
5 mm diameter locking holes for medial or lateral locking; the
"' most distal hole is 20 mm from the tip of the nail, the second
~ 30 mm from the first, measured from the centres of the holes.
·2' The AO/ASIF universal femoral nails can be used for either the
'5 right or the left leg. It is currently available with a diameter of 11
~
....., to 18 mm in lengths from 300 to 480 mm in 20 mm increments,
"CS
; and with a 19 mm diameter in lengths from 380 mm to 480 mm.
=
-=e
.~
~ Universal Tibial Nail
This nail was introduced shortly after the universal femoral nail,
-2
-
also following extensive clinical and biomechanical studies. The
~ characteristic features of this nail are similar to those of the
• 284
femoral nail. It is made of a tube with 1.2 mm wall thickness and
a cloverleaf cross-section. It has a continuous longitudinal slot
on the dorsal aspect, formed as a keystone at the proximal end.
The full-length slot prevents stress concentration, particularly
under torsion, and ensures an even distribution of stress over
the whole length of the nail. The keystone slot prevents widen-
ing of the nail end when tightening the threaded conical bolt.
The inner conical thread of the proximal end has the same con-
figuration for all nail sizes. This allows the same insertion/ex-
traction instruments to be used for all nail diameters.
The anterior aspect of the proximal end is bevelled to prevent ir-
ritation of the overlying soft tissue and patellar tendon. The two
notches accept the lugs of the insertion handle, positioning the
handle for right or left leg insertions. The nail has a bend at the
transition between the middle and the proximal third. This bend
takes into account the anatomical angle of about 11 o formed by
the axis of the access canal, and that of the medullary canal. The
bend greatly facilitates insertion. The tapered tip of the nail en-
sures sliding of the nail along the guide rod without penetration
of the posterior cortex.
For locking of the nail, there are three holes both proximally
and distally. The proximal three holes are used for mediolateral
locking. The middle, slotted one is used for dynamic locking,
and the two 5 mm diameter round holes for static locking. Two
of the distal holes, the most distal and the most proximal, are
orientated mediolaterally, and the middle hole antero-posteri-
orly. The antero-posterior ( AP) hole is used if medial soft tissue
coverage is inadequate or if the proximal mediolateral hole is
too close to the fracture site. The most distal mediolateral hole
is 20 mm from the nail end, and the second mediolateral hole
30 mm from the first hole.
The universal tibial nail is at present available with diameters of
-==
11 mm, 12 mm, and 13 mm lengths from 285 mm to 360 mm in
15 mm increments, and from 380 mm to 400 mm in 20 mm in- "'
crements. A 10 mm diameter nail with round cross-section is be-
-=a=
Q.
ing introduced. This nail is only used for interlocking.
-=a
"C
Locking Bolts, 4.9 mm Diameter
"'
These bolts have a core diameter of 4.3 mm and are fully thread-
--=..=
~
ed. The 8 mm diameter head profile is low, 2.5 mm, to ensure

better soft tissue coverage. The 3.5 mm hexagonal socket allows "'
the use of the large hexagonal screwdriver. The self-cutting tro- Oil
car tip of the bolt permits easy insertion into the 4.0 mm drill :5
·;
hole. The flat thread safely engages in both the nail and the z
="
bone, if the 4.0 mm drill bit is used to pre-drill for the slightly
larger core size. Backing out of the bolt is thus prevented. Tap- .!
ping is not necessary. When measuring the length for the locking "C
~ a
--=
~
bolt, a 2 mm longer locking bolt than measured must be chosen.

'· L
+ 2mm
~I The tip of the bolt will then pass through the bone on the oppo-
E
285 •
site side, allowing secure engagement of the thread in the far
cortex.
The same locking bolt is used for both femoral and tibial nails. It
is available in lengths from 26 mm to 60 mm in 2 mm incre-
ments, from 64 mm to 80 mm in 4 mm increments, and from
85 mm to 100 mm in 5 mm increments.
Important dimensions: 4,0 3.5
- Head diameter: 8.0mm j
- Head height:
- Hexagonal socket:
2.5mm
3.5mm 4.3
••••
4.
- Core diameter: 4.3mm
- Drill bit for pilot hole: 4.0mm
6.12.5 Technique of Insertion and Locking

of Universal Femoral and Tibial Nails
Open Versus "Closed" Intramedullary Nailing

In "closed" nailing technique, a fracture table, or distractor, is
used for reduction out to length. Image intensifier is necessary
to control reduction and reaming. This technique minimises
damage to soft tissue and to the periosteal and muscular blood
supply, and reduces blood loss. Although technically demand-
ing, closed nailing is the preferred method.
In the open nailing technique, the fracture is exposed and re-
duced under direct vision. The patient may be positioned on a
standard table, which is of advantage in, for example, polytrau-
matised patients.
Correct Position of the Image Intensifier

If universal nails are inserted by "closed" means, or if a locking
technique is planned, an image intensifier is required. It is nec-
essary to control the fracture zone during reduction whilst in-
serting the reaming rod, the reamers, and the nail. In locked
nailing, the image intensifier is additionally used for insertion of
t the locking bolts. Both AP and lateral views are necessary.
§.. For the locking procedure, the X-ray source (S) must be placed
] near the bone opposite the incision. This leaves enough distance
~ (d) between receiver head (R) and the leg to allow use of the
"C drill bit and the locking instruments.
c
=
c
For locking of the femoral nail the X-ray source is placed medi-
-
e ally near the bone, with the receiver head laterally.
;
= For locking of the tibial nail the X-ray source is placed laterally
c
~ near the bone, and the receiver head medially.
-...~
...."c
• 286
6.12.5.1 Insertion of the Universal Femoral Nail
Positioning of the Patient
Lateral Positioning on a Fracture Table

A fracture table with long cantilever extensions is used. The pa-
tient is placed in a lateral decubitus position, with the pelvis held
exactly vertical by pelvic supports on both sides of the table. The
perineum rests on a well-padded perineal post, with the genitals
in male patients freely mobile. A traction wire is inserted
through the very distal portion of the femur.
Supine Positioning on a Fracture Table

The leg of the injured femur is allowed to hang with the knee
flexed at 90 o. The patient's pelvis should lie flat on the table to
ensure correct rotational alignment of the femur. Rotation can-
not be corrected. If possible, slightly adduct the injured leg at
the hip. A traction wire is inserted through the very distal por-
tion of the femur.
Lateral Positioning on a Standard Table

The patient is placed in lateral position; a vacuum mattress may
be helpful. The injured leg is flexed forward at the hip at about
45 °, with the knee bent to 90° and the foot placed on the unin-
jured leg. A distractor may be used for reduction.
Supine Positioning on a Standard Table

The uninjured leg is abducted at the hip and the injured leg ad-
ducted. A dis tractor may be used for reduction.
Reduction Technique
Reduction Using the Fracture Table

Reduction of femur fractures on a fracture table may be difficult
in that restoration in all three planes (frontal, sagittal, and hori-
zontal) has to be obtained and maintained during surgery. Using
skeletal traction and careful manipulation, reduction in the
frontal and horizontal planes can be achieved. Maintaining re-
duction in the sagittal plane is more difficult. An external sup-
port may have to be applied.
287
•
Reduction Using the Large Distractor
The large distractor may be applied temporarily for gentle re-
duction in "closed" or open nailing procedures. It makes the use
of a fracture table unnecessary. See Sect. 6.14.1.3.

- After opening the proximal medullary canal, and insertion of
the reaming rod, the proximal fragment is reamed to 11 mm.
See reaming technique below.
- The 11 mm manipulation nail is mounted with the corre-
sponding size insertion handle and locking nut, and inserted
as far as possible into the medullary canal.
- The curved aiming attachment is fitted on the insertion han-
dle and the 6.0 mm/5.0 mm/3.5 mm drill sleeve assembly with
trocar inserted at the top of the curved aiming attachment. It
has to be positioned so that the drilling axis is orientated in an
AP direction to avoid the femoral neuro-vascular bundle.
The cut c-c (a) is shown in the figure (b).
- A stab incision is made through the soft tissue, and the trocar
and drill sleeve assembly pushed down onto the bone. The
trocar is then removed.
- The three-fluted 3.5 mm drill bit, 225 mm/200 mm long, is
used with the oscillating attachment on the small air drill to
drill the both cortices.
- A 5 mm Schanz screw, 200 mm long, is inserted through both
cortices using the universal chuck with T handle. The Schanz
screw is perpendicular to the nail axis.
- A second Schanz screw is inserted through a stab incision in
the condyles about 2 em above the knee joint, parallel to the
joint.
- The prepared distractor is mounted on the Schanz screws so
that the axis of its threaded rod is parallel to the proximal
fragment of the femur, and fixed by tightening all nuts in neu-
tral position (observe markings).
- The distal carriage and the proximal sleeve-holding bracket
permit movement about several axes and in several planes.
Each joint can be fixed and released separately.
- The fracture is reduced by slight traction using the inner nut
at the distal end. Torsion of fragments relative to each other
may be prevented by holding the Schanz screws manually
during distraction. Excessive traction must not be applied.
- After reduction the reaming procedure can continue and the
nail be inserted (technique see below) with the distractor in
place. The distractor is removed after nail insertion.
- Open reduction of the fracture under direct vision may be of
advantage in certain fractures.
• 288
Determining the Femoral Nail Length and Diameter
The appropriate nail length can be determined before surgery

by using the patient's uninjured leg as a guide. The distance from
L the tip of the greater trochanter to the joint line of the knee is
measured, and 20--30 mm subtracted (a). The length of nail may
also be determined during surgery by measuring the exposed
portion of the reaming rod. Length A is subtracted from the
rod's total length of 950 mm (b). Comparative measurement
can be made by holding a guide rod of the same length parallel
to the exposed rod. The tip of the rod (c) is aligned with the
E point of insertion (i). The length from the free end of the ream-
E
A 0
It)
ing rod to the end of the guide rod is the nail length L. This
0> length of nail, as well as the next longer and the next shorter
nails are prepared. If a nail is inserted without locking, the cor-
rect length nail is of great importance. Too short a nail and ade-
quate stability is not achieved. Too long a nail may damage the
knee joint when inserted, or may be impossible to insert at all.
The nail diameter will depend on the fracture pattern and local-
isation. Locked nails are in general of small diameter. In trans-
verse and short oblique midshaft fractures reaming is per-
formed to ensure tight fitting of the nail in the fracture zone.
The diameter of the nail may in this case be determined either
by measuring the medullary canal on the X-ray prior to surgery
or during surgery by referring to the last used reamer.
Point of Insertion
The point of insertion for the universal femoral nail lies in the
extrapolation of the axis of the medullary canal- the piriformis
fossa. It is of great importance that the correct insertion point be
chosen, since the rather stiff nail would otherwise be caused to
twist excessively during insertion, or could damage the proxi-
mal fragment.
Insertion Technique
Opening the Medullary Canal:

- The trochanteric region is exposed. The centring pin, held in
the universal chuck with T handle, is positioned on the femur
at the site of the piriformis fossa. By turning and pressing
simultaneously, the pin is inserted about 50 mm into the
medullary canal.
- The handle is removed.
- The cannulated cutter is passed over the pin and the Allen
screw tightened with the large hexagonal screwdriver. To
open the medullary canal, the cannulated cutter is rotated
180 o and then turned back. It must not be hammered.
289
•
- The reaming rod with offset ball tip is mounted in the univer-
sal chuck with T handle and inserted, under image intensifica-
tion, across the fracture site as far as the condylar mass. Its
correct position is checked in both planes.
Reaming the Medullary Canal:

- The flexible shaft with fixed front-cutting reamer, 9 mm di-
ameter, is pushed over the reaming rod and connected with
the right-angle drive assembled with the universal air ma-
chine. The holding forceps (or the old style holder) is used to
hold the rod in position and prevent rotation during the ream-
ing procedure. The tissue protector is placed between the soft
tissue and the flexible shaft at the insertion point.
- Reaming starts only when the reamer is in the medullary
canal. Reaming speed should be about 300-350 rpm. The
reaming progresses slowly and is interrupted by occasional
backward movement to clear the canal of debris. The reamer
progress is halted by the offset ball tip of the reaming rod.
Reamer depth is checked with image intensification.
- The flexible shaft is removed fully while the reaming rod is
held in place with the holding forceps at the entry of the
medullary canal. If the reaming rod backs out, the reduction
maybe lost.
- The 9.5 mm diameter reamer is mounted on the 8 mm flexi-
ble shaft and held with two fingers until placed over the ream-
ing rod. The power drill is connected, and the reaming to the
desired size continued as described above.
- The reamers should be used in increments of 0.5 mm to min-

"'
= imise heat generation and to reduce the risk of jamming. If
(j,j
·a~
the 13 mm diameter reamer is used, the 8 mm flexible shaft
'5 must be exchanged for the 10 mm shaft or else the reamer will
~
'""""' Jam.
"CC
; - If a reamer jams, the reaming must be stopped immediately.
.::=
--
=
=
(j,j
For removal of a jammed reamer, see illustration on p. 275 .
e
-e="'
-
• 290
- After completion of reaming, the medullary tube is passed
over the reaming rod, to hold the reduction.
- If not measured prior to surgery, the correct length of the uni-

versal femoral nail is determined by measuring the exposed
length of the guide rod and subtracting this measurement
from the total length of 950 mm (seep. 289). The nail diame-
ter is determined by the last used reamer. If necessary, a nail
of 0.5-1 mm smaller diameter is chosen. The diameter is
checked by using the measuring gauge. The reaming rod is
then removed. The 4 mm guide rod is inserted into the
medullary tube, and the tube removed.
Insertion of the Femoral Nail:

- The nail, with the slot directed anteriorly, is passed over the
guide rod and pushed by hand into the medullary canal as far
as possible.
- The correct size threaded conical bolt is slid over the guide
rod and tightened slightly with the combination wrench. The
corresponding size insertion handle is placed over the bolt
with the lugs engaging the notches ofthe nail end. The thread- "'
ed conical bolt is then firmly tightened, and the locking nut =
1:':1
"S.
fitted and tightened.
- The ram guide is screwed on the threaded conical bolt, the
.s
=
-
'C
ram passed over the ram guide, and the flexible grip screwed 1:':1
on the ram guide. "'

=
e
..
--
Q,l
- The nail is inserted with controlled blows by the ram, using
the insertion handle to control rotation. Letting the ram fall =
from a distance should actually move the nail5- 10 mm. "'
=
- The guide rod retainer is inserted in the ram guide to hold the 1:1)
guide rod in position until the nail is finally positioned. If the :S

·;
guide rod is allowed to back out, the reduction may be lost z
and the nail inserted wrongly. The flared end of the nail
should not be driven into but should "sit" on top of the bone.
E
'3
'C
..e
Q,l
--
1:':1
=
291 •
- The ram guide, ram, flexible grip, and guide rod are removed.
If locking is planned the insertion handle, threaded conical
bolt and locking nut are left in place.
Note: If desired, the insertion can be carried out by using the
curved driving piece, the driving head, and an 800 g hammer in-
stead of the "long" assembly of ram guide and ram.
The insertion handle, threaded conical bolt and locking nut are
removed as follows:
- The locking nut is loosened by a half turn.
- The insertion handle is held firmly with the lugs in the nail
notches.
- The threaded conical bolt is now detached using the combina-
tion or socket wrench.
Note: This technique must always be employed when removing
the threaded conical bolt or the nail end may distort and cause
jamming of the bolt.
6.12.5.2 Locking of the Universal Femoral Nail
The locking procedure is carried out using the special instru-

ments for distal and proximal locking. The distal locking is per-
formed when control of a short distal fragment is required. It is
also used when static locking is required to control tendency to
shorten or rotate at the fracture site. In general, distal locking is
performed first. If necessary, manipulation of the locked distal
fragment using the insertion handle is then possible.
Distal Locking of the Femoral Nail

Using the Radiolucent Drive
Simple free-hand locking technique may be performed by using

the radiolucent drive attached to the small air drill, and the
4.0 mm diameter three-fluted drill bit for radiolucent drive.
- The image intensifier is aligned until the locking hole is abso-
"'~ lutely round.
·=:=" - After incision the radiolucent drive is positioned with the tip
'5 of the 4.0 mm drill bit centred on the locking hole. Only the
~ drill bit and the centring ring are visible whilst all other parts
'1:l
; of the gear housing remain invisible.
c - Still under image intensification the radiolucent drive is tilted
.~
~ until the drill bit appears as a single dot in the centre of the
~ locking hole. The centring ring acts as an additional reference
!5 for positioning.
-2 - The drill is held firmly in this position, while drilling both cor-
-~ tices (Fig. 1). The drill bit should not be forced through the
• 292
bone, but cut its way through. Image intensification may be
needed to assure that the drill bit stays centred.
- The depth gauge is used to measure the length. The hook
must engage the far cortex and not only the nail (Fig. 2).
- A 4.9 mm locking bolt, 2 mm longer than measured, is insert-
ed using the large hexagonal screwdriver, and firmly tight-
ened. The tip of the locking bolt should then protrude out of
the far cortex to provide reliable support (Fig. 3).
- The second locking bolt is inserted using the same technique
as that for the first locking bolt (Fig.4).
Proximal Locking of the Femoral Nail
The proximal locking bolts are inserted using the insertion han-
dle for aiming. Image intensification is not necessary. For lock-
ing of femoral nails the handle is placed laterally.
- The 11 mm/8 mm protection sleeve and trocar are inserted
through the desired hole of the insertion handle. The most
proximal hole is for dynamic locking and is clearly marked.
- The 8 mm/4.5 mm drill sleeve is inserted, and the 4.0 mm/
4.5 mm drill bit used to drill through both cortices (Fig.1).
- The drill bit and drill sleeve are removed and the depth gauge
inserted through the protection sleeve to measure the length.
The hook must engage the far cortex, not the nail (Fig. 2).
ed using the large hexagonal screwdriver and tightened firm-
ly. The tip of the bolt should protrude out of the far cortex to
provide reliable support (Fig. 3).
293
•
- The second locking bolt is inserted using the same procedure
(Fig.4).
- Removal of the insertion handle, threaded conical bolt and
locking nut as follows (Fig. 5).
The locking nut is loosened by a half turn.
The insertion handle is held firmly with the cams in the
notches.
The threaded conical bolt is now unscrewed using the com-
bination wrench, or the socket wrench and the instruments
removed (Fig. 6).
Distal Locking of the Femoral Nail Using the Distal Aiming

Device Assembly and 4.0 mm/4.5 mm Drill Bit
Distal locking may be achieved by using the distal aiming device

assembly. If used accurately, aiming for the locking holes is quite
simple. Image intensification is necessary also for this tech-
nique. The leg of the patient must be placed between the X-ray
source and the aiming device, because of the device's built in
correction of the 4 o divergence of the X-ray beam.
- The image intensifier is positioned so that the picture on the
monitor and the orientation of the leg correspond. The nail
should be shown in the lower half of the monitor with the
more proximal hole in the middle. The image intensifier is
moved until this hole appears absolutely round on the moni-
tor and is then fixed in this position. On no account should the
C arm, or the leg, be moved again until drilling is finished
(Fig.l).
- The radiation shield is placed on the patient's leg to protect
the surgeon's hands. However, the shield should not extend
into the window of the monitor, to prevent the radiation level
"'~ from being automatically raised.
·a - The tip of a scalpel is placed over the locking hole under im-
"8 age intensification to mark the incision. For the femur one
~ single incision for both locking holes may be more convenient
] than two single ones (Fig. 2).
~
c
-e=
0
·.;
c
~ 2
......
~
-
•
It!
294
- The distal aiming device and trocar are pushed through the
incision onto the bone (Fig. 3).
- The trocar is removed and the aiming trocar inserted. The
axis of the aiming device is adjusted to centre the direction
finder's central dot in the circle (Fig. 4).
- The device is then moved along the long axis of the bone until
the dot nearest the handle of the aiming trocar is located in
the centre of the locking hole. This position should be main-
tained throughout the drilling procedure (Fig. 5). Accidental
displacement of the distal aiming device is prevented by tap-
ping the sharp tips slightly in the bone, once they are in the
correct position.
- The aiming trocar is removed and the 8 mm/4.5 mm drill
sleeve inserted. Image intensification is used to check that the
5 hole in the nail is circular and concentric with the drill sleeve.
- The 4.0 mm/4.5 mm drill bit is used to drill both cortices, pass-
ing through the locking hole. The direction is controlled by
checking that the centred dot of the direction finder remains
centred in the circle (Fig. 6).
- After removal of the drill sleeve and the protection sleeve, 'IJ
the depth gauge is used to measure the length directly i

through the distal aiming device. The hook must engage the
far cortex, not the nail, before the outer sleeve is pushed onto -
"S.
s
-s=
"C
the bone and the measurement read (Fig. 7). =
e'll
'IJ
--==...
~
' IJ
- The femoral fixation bolt is inserted through the aiming de-

C ll
vice and tightened. It holds the distal aiming device in a fixed :S
position while preparing for the second locking bolt (Fig. 8). ·;
z
~
.!
'3
"C
s
~
--=...
~
295 •
- The large hexagonal screwdriver is used to loosen one of the
Allen screws of the direction finder. This is turned until its
two straight metal markers are parallel with the nail on the
monitor. The exact distance between the two locking holes is
determined by correct placement of the direction finder. The
hole of the direction finder will not therefore appear coaxial
with the second locking hole (Fig. 9).

into the second hole of the direction finder, and pushed onto
the bone through a second stab incision (or through the com-
bined incision already made) (Fig.10).
- The trocar is removed and the 4.5 mm drill sleeve inserted.
The 4.0 mm/4.5 mm drill bit is used to drill both cortices, pass-
ing through the nail (Fig.ll).
- The 4.5 mm drill sleeve is removed and the length measured
with the depth gauge through the protection sleeve (Fig. 12).
- The chosen 4.9 mm locking bolt, 2 mm longer than measured,
is inserted and firmly tightened using the large hexagonal
screwdriver through the 11 mm/8 mm protection sleeve
(Fig.13). The protection sleeve is then left in this position.
- The femoral fixation bolt in the first drilled hole is removed
and the chosen locking bolt (2 mm longer than measured) in-
serted and firmly tightened (Fig. 14).
- The distal aiming device assembly is then removed (Fig.15).
"'
~
·a=
Q"
.c
(,J
~
-=ea
=
--=e
=
·=ea
~
-..==
...."'
• 296
6.12.5.3 Insertion of the Universal Tibial Nail
Supine Position on a Fracture Table

The knee of the injured leg is bent 90 o and extended obliquely
downwards. A pad is used to support the distal femur at a suffi-
cient distance from the popliteal artery and vein (A and V).
Extension can be applied by a padded boot or by calcaneal trac-
tion. If distal locking is planned traction has to be used, since the
boot extends too far proximally, and obstructs access to the
locking area.
The uninjured leg is placed in abduction, flexion, and external
rotation at the hip to ensure free movement of the image inten-
sifier.
The C arm of the image intensifier must have free movement in
AP and mediolateral directions. Reduction and correction of
rotation must be carried out before sterile draping since it is dif-
ficult to adjust during surgery.
Supine Position on a Standard Table

A radiolucent table is necessary. The knee is bent and held by an
assistant during surgery.
Reduction Techniques
With the patient positioned on a fracture table, reduction may

be carried out by applying traction and manually adjusting the
fragments. Final reduction is achieved during operation using
the angled offset ball tip of the reaming rod to "navigate" across
the fracture.
With the patient positioned on a standard table the following re-
duction techniques may be considered:
- The leg is hanging using a side support.
- Tight application of an Ace bandage or a sterile, extra-wide
pneumatic tourniquet.
- Application of the distractor with the Schanz screws inserted
in the frontal plane as close to both tibial ends as possible.
- Open reduction and temporary fixation of the fracture using
a plate applied to the tibial crest by two Verbrugge clamps.
297 •
Determining the Nail Length and Diameter - ;-- --
The nail length can be determined prior to surgery by measur-
ing the uninjured leg from the knee joint line to the tibiotarsal
L
joint and subtracting 30--40 mm (a). The length may also be de-
termined by measuring the exposed portion of the reaming rod
(b). Length A is subtracted from the rod's total length of
950 mm (b). Comparative measurement can be made by hold-
I
ing a guide rod (c) of the same length parallel to the exposed
rod. The tip of the rod is aligned with the point of insertion (i).
The length from the free end of the reaming rod to the end of the
E
guide rod is the nail length L. Nails of this length, one 15 mm E
longer and one 15 mm shorter are prepared. 0
L+ IJ)
The nail diameter depends on the fracture pattern and localisa- A
0)
tion. In simple transverse or short oblique fractures where

reaming is used, the largest reamer used will indicate the diame-
ter. If necessary, a nail of 0.5 mm smaller diameter is chosen. /,..-,
i.e:::'
~~ , c
I
L I
I
I
~
b
p
Point of Insertion
The point of insertion lies slightly offset medially, and slightly M
proximal to the tibial tuberosity in line with the medullary canal.

It must be sufficiently below the intercondylar area to avoid
damage to the joint. A 60 mm longitudinal incision is made me-
dial to the patellar ligament. The tendon is then retracted later-
ally.
Insertion Technique
Opening the Medullary Canal:

- The 4 mm centring pin is mounted in the universal chuck with
T handle and positioned over the insertion point. The univer-
sal tibial nail is placed alongside the tibia to act as an "angle
guide".
- The pin is inserted in the medullary canal parallel to the up-
per end of the nail by turning and pressing simultaneously.
The handle is removed.
• 298
- The cannulated cutter is passed over the pin and the Allen
screw tightened with the large hexagonal screwdriver. To
open the medullary canal, the cannulated cutter is rotated
180 o and then turned back. It must not be hammered.
- The reaming rod with offset ball tip is mounted in the univer-
sal chuck with T handle, and inserted under image intensifica-
tion across the fracture site as far as the distal metaphyseal
mass.lts correct position is checked with the image intensifier
in both planes.
Reaming the Medullary Canal:

- The flexible shaft with fixed front-cutting reamer, 9 mm in di-
ameter, is pushed over the reaming rod , and connected to the
right -angle drive assembled on the universal air machine.
- The holding forceps (or old style holder) is used to hold the
rod in position and prevent rotation during the reaming pro-
cedure. The tissue protector is placed between the soft tissue
and the flexible shaft at the insertion point.
- Reaming starts only when the reamer is in the medullary
canal. Reaming speed should be about 300-350 rpm. The
reaming progresses slowly and is interrupted by occasional
backward movement to clear the canal of debris. The reamer
is halted by the offset ball tip of the reaming rod. Reamer
depth is checked with image intensification.
- The flexible shaft is removed. The reaming rod is held in place
with the holding forceps at the entry of the medullary canal
after the reaming head has been withdrawn from the bone. If
the reaming rod backs out the reduction may be lost.
- The 9.5 mm diameter reamer is mounted on the 8 mm flexi-
ble shaft and held with two fingers until placed over the ream-
ing rod. The power drill is connected, and reaming to the de-
sired size is continued as described above.
-=
"'
co:
-=e
Q.
"Q
-=e
co:
"'
.s-
~
- The reamers should be used in increments of 0.5 mm to min- 2

imise heat generation and to reduce the risk of jamming. If "'
eiJ
the 13 mm diameter reamer is used (rare in tibial nailing), the
8 mm flexible shaft has to be exchanged for the 10 mm shaft
:S
·;
or else the reamer will jam. If a reamer jams, reaming must be z
stopped immediately. For technique of removal of a jammed
t'
.!
reamer, see illustration on p. 275.
=e
"Q
--..=
- If not measured prior to surgery, the correct length and diam- ~
eter of the universal tibial nail is determined (seep. 298). co:
299
•
- The medullary tube is passed over the reaming rod to hold re-
duction.
- The reaming rod is then removed.
- The 3 mm guide rod with flattened ends is inserted.
Insertion of the Universal Tibial Nail:

- The nail is passed over the guide rod and pushed into the
medullary canal by hand as far as possible.
- The threaded conical bolt for tibial nails is pushed through
the insertion handle, the assembly slid over the guide rod and
tightened slightly by the combination wrench. The lugs of the
insertion handle sleeve must engage the notches of the nail
end before the threaded conical bolt can be firmly tightened,
followed by the locking nut. For insertion of the nail, the han-
dle can be positioned either medially or laterally.
• 300
- For insertion, the curved driving piece is screwed on the
threaded conical bolt leaving 3 mm clearance between the
curved driving piece and the first thread of the threaded coni-
cal bolt. This is necessary to avoid jamming. The guide rod
~ 2-3 mm
protrudes at the hexagonal socket end. The angled end of the
curved driving piece is pointing posteriorly.
- The driving head is screwed on, and the 800 g hammer used to
insert the nail with controlled blows, while the guide rod is
held in place with the holding forceps. Each blow should ad-
vance the nail further into the medullary canal.
- If insertion is difficult, reaming 0.5-1 mm further may be
necessary.
- The nail is inserted until the proximal end of the nail is flush
with the surface of the cortex at the point of insertion. If the
correct length has been chosen, the tip of the nail should lie in
the distal metaphysis.
- The curved driving piece, the driving head, and the guide rod
are removed.
- If locking of the nail is planned, the insertion handle, thread-
ed conical bolt, and locking nut are left in place. The handle
must then be placed medially for locking.
The insertion handle, threaded conical bolt and locking nut are
removed as follows:
- The locking nut is loosened by a half turn.
- The insertion handle is held firmly with the lugs in the notches
- The threaded conical bolt is now detached using the combina-
tion or socket wrench.
Note: This technique must always be employed when removing -=
"'
-a=
the threaded conical bolt or else the nail end may distort and
cause jamming of the bolt. -==
8
-=
"C
Note: The nail may be inserted by using the ram guide and the
ram. The following technique is then employed:
"'
Col
.s-
- The ram guide is screwed on the threaded conical bolt, the 8
ram passed over the ram guide and the flexible grip screwed
2
on the ram guide.
"'
~
- The nail is inserted with controlled blows by the ram, using :.§
the insertion handle to control rotation. Letting the ram fall ·;
from a distance should actually move the nail 5-10 mm. The
:z
~
flared end of the nail should not be driven into, but should .!
"sit" on the top of the bone. =8
"C
Col
--=
- The ram guide, ram, flexible grip, and guide rod are removed.
f
301
•
6.12.5.4 Locking of the Universal Tibial Nails
The locking procedure is carried out using the special instru-

ments for distal and proximal locking. The distal locking is per-
formed when control of a short distal fragment is required. It is
also used when static locking is required to control tendency to
shorten or rotate at the fracture site. In general, distal locking is
performed first, because if the distal fragment has to be manipu-
lated after locking this is best done by using the insertion handle
from the proximal end.
Distal Locking of the Universal Tibial Nail

Using the Radiolucent Drive
Simple free-hand locking technique may be performed by using

the radiolucent drive attached to the small air drill, and the
4.0 mm diameter three-fluted drill bit for radiolucent drive.
- The image intensifier is aligned until the locking hole is abso-
lutely round (Fig. l).
- After the incision, the radiolucent drive is positioned with the
tip of the 4.0 mm drill bit centred on the locking hole. Only
the drill bit and the centring ring are visible, whilst all other
parts of the gear housing remain invisible (Fig. 2).
- Still under image intensification, the drill bit is tilted until the
drill bit appears as a single dot in the centre of the locking
hole. The centring ring acts as an additional reference for po-
sitioning (Fig. 3).
"'
Q,l
·a=
2
C"
.c
~
~
-=
=
--=
~
=
.~
~
..-e=
Q,l
...."'
= • ~ 3
• 302
- The drill is held firmly in this position, while drilling both cor-
tices. The drill bit should not be forced through the bone, but
cut its way through. Image intensification may be needed to
assure that the drill bit stays centred (Fig. 4).
- The depth gauge is used to measure the length. The hook
must engage the far cortex and not only the nail (Fig. 5).
ed using the large hexagonal screwdriver and firmly tight-
ened. The tip of the locking bolt should then protrude out of
the far cortex to provide reliable support (Fig. 6).
- A second locking bolt is inserted using the same technique
(Fig. 7).
Proximal Locking of the Universal Tibial Nail
The proximal locking bolts are inserted using the insertion han-
dle for aiming. Image intensification is not necessary. For lock-
ing of tibial nails the handle must be turned medially.
through the desired hole of the insertion handle to mark the
stab incision. The middle hole is for dynamic locking and is
clearly marked. The sleeve and trocar are pushed onto the
-=
"'
c.
~
bone. The trocar is then removed (Fig.l). .5

=
"C
- The 8 mm/4.5 mm drill sleeve is inserted and the 4.0 mm/
-e
~
4.5 mm drill bit used to drill through both cortices (Fig. 2). "'
- The drill bit and drill sleeve are removed and the depth gauge =
--=
~
inserted through the protection sleeve to measure the length. 2

The hook must engage the far cortex, not the nail (Fig. 3). "'
~
:§
·;
z
~
.:s
=e
"C
--=
~
303 •
ed using the large hexagonal screwdriver, and tightened firm-
ly. The tip of the bolt should protrude out of the far cortex to
provide reliable support (Fig.4).
- The second, and, if necessary for stability, a third bolt are in-
serted using the same technique (Fig. 5).
4
- Removal of the insertion handle, threaded conical bolt and
locking nut as follows:
The locking nut is loosened by a half turn.
The insertion handle is held firmly with the lugs in the
notches.
The threaded conical bolt is now unscrewed using the com-
bination wrench, or the socket wrench and the assembly re-
moved (Fig. 6). 5
Distal Locking of the Tibial Nail Using the Distal Aiming

6
Device Assembly and 4.0 mm/4.5 mm Drill Bit
By using the distal aiming device assembly accurately, aiming

for the locking holes is quite simple. Image intensification is
necessary also for this technique. The leg of the patient must be
placed between the X-ray source and the aiming device because
of the device's built in correction of the converging X-ray beam.
- The image intensifier is positioned so that the picture on the
monitor and the orientation of the leg correspond. The nail
should be shown in the lower half of the monitor with the
more proximal hole in the middle. The image intensifier is
moved until this hole appears absolutely round on the moni-
tor, and is then fixed in this position. On no account should
2
the C arm or the leg be moved again until drilling is finished.
- The radiation shield is placed on the patient's leg to protect
the surgeon's hands. The shield, however, should not extend
into the window of the monitor, to prevent the radiation level
from being automatically raised.
- The tip of a scalpel is placed over the locking hole under im- 3
"'~
·a -
age intensification to mark the incision.
The distal aiming device and trocar are pressed onto the cor-
'5 tex (Fig.l).
~ - The trocar is removed and replaced with the aiming trocar
"CC
;j (Fig. 2).
.::=
--
- The axis of the aiming device is then adjusted to centre the di-
rection finder's central dot in the circle.
= 4
= - The device is then moved along the long axis of the bone until
-..
Q,j
5 the second dot of the aiming trocar is located in the centre of

= the locking hole. This position should be maintained through-
...="' out the drilling procedure .
• 304
- Accidental displacement of the distal aiming device is pre-
vented by tapping the sharp tips slightly in the bone, once it is
in the correct position.
- The aiming trocar is removed and the 8 mm/4.5 mm drill
sleeve inserted. Image intensification is used to verify that the
5
hole in the nail is circular and concentric with the drill sleeve.
- The 4.0 mm/4.5 mm drill bit is used to drill both cortices, pass-
ing through the locking hole. The direction is controlled by
checking that the central dot of the direction finder remains
centred in the circle (Fig. 3).
- After removal of the drill sleeve and the protection sleeve,
the depth gauge is used to measure the length directly
through the distal aiming device. The hook must engage the
6
far cortex, not the nail, before the outer sleeve is pushed onto
the bone and the measurement read (Fig.4).
- The tibial fixation bolt is inserted through the aiming device
and tightened. It holds the distal aiming device in a fixed posi-
tion while preparing for the second locking bolt (Fig. 5).
- The large hexagonal screwdriver is used to loosen one of the
7 Allen screws of the direction finder, and to turn it until its two
straight metal markers are parallel with the nail on the moni-
tor. The exact distance between the two locking holes is deter-
mined by correct placement of the direction finder. The hole
of the direction finder will not therefore appear coaxial with
the second locking hole.
8 into the second hole of the direction finder, and pushed onto
the bone through a second stab incision (Fig. 6).
- The trocar is removed and the 4.5 mm drill sleeve inserted.
The 4.0 mm/4.5 mm drill bit is used to drill both cortices, pass-
ing through the nail (Fig. 7).
- After removal of the drill bit and drill sleeve, the length is
measured with the depth gauge through the protection sleeve
9
(Fig.8).
- The chosen 4. 9 mm locking bolt, 2 mm longer than measured,
is inserted and firmly tightened using the large hexagonal
screwdriver through the 11 mm/8 mm protection sleeve
(Fig. 9). The sleeve is then left in this position.
- The fixation bolt is removed and the chosen locking bolt
(2 mm longer than measured) inserted and firmly tightened
in the first hole (Fig.lO).
10 - The distal aiming device assembly is then removed (Fig.11 ).
- In universal tibial nails, the AP hole is prepared in similar
manner.
- The C arm is turned 90 ° placing the leg between the X-ray
source and aiming device.
11
305 •
6.12.5.5 Dynamisation of the Universal Nails
There may be indications to reduce the "stiffness" of the fixa-

tion, allowing increasing load to be transmitted through the
bone. The progress of bone healing may thereby be stimulated.
The removal of locking screws- some or all - is one technique
for achieving such "dynamisation".
Dynamisation can be obtained by removing the locking bolt
placed in the "static" hole. The locking bolt in the elongated
hole may then "move" proximally allowing axial load at the
fracture site, but still providing rotational stability of the frac-
ture.
6.12.5.6 Instruments for the Insertion and Removal

of Universal Femoral and Tibial Nails
Instruments for insertion universal femoral nails
-=--------------~--------------~;-
•••••••••••••••••
"' ••••••••••
...=
~
C"
=
..c:
~
~
"C
=
~
...0=
~
-=
~
-..=~
"'
• 306
Instruments for insertion of universal tibial nails
J
•••••••••••••••••
•••••••••• ~===...., :)
Instruments for locking of universal femoral and tibial nails

using the radiolucent drive
Instruments for locking of universal femoral nails using the aim-

ing device
307 •
Instruments for locking of universal tibial nails using the aiming
device
Instruments for removal of the universal femoral nails
Instruments for removal of the universal tibial nails
• 308
The universal nails are in general removed. Tibial nails are
usually removed after 18-24 months, femoral nails after 24-
36 months.
- Locking bolts are first removed through stab incisions distally
and proximally for tibial nails. For femoral nails the bolts are
removed through the main distal incision. The proximal bolts
are removed through incisions indicated by using the inser-
tion handle and 11 mm/8 mm protection sleeve and trocar.
- After opening the site for the proximal nail end, the nail is
carefully freed of ingrown soft tissue to clear the inner
threads.
- The threaded conical bolt, insertion handle, and locking nut
of correct size (corresponding to the nail type and size) is
screwed in the nail end, and tightened firmly with the socket
wrench or the combination wrench. The lugs of the insertion
handle sleeve should engage the notches of the nail end. The
insertion handle is necessary to prevent jamming of the
threaded conical bolt in the nail end, when the nail is re-
moved. It also serves to direct the screwdriver through appro-
priate stab incisions, using the 11 mm/8 mm protection sleeve
when removing proximal femoral locking bolts.
- The ram guide is screwed onto the threaded conical bolt, the
ram slid on, and the flexible grip attached. By means of strong
blows against the flexible grip, the nail is driven out. Re-tight-
ening the instruments after the first few blows prevents unde-
sired loosening.
6.12.5.7 What If the Nail Cannot Be Removed

by the Standard Method?
If the nail is firmly anchored by bony ingrowth, it may be dis-

lodged by first driving the nail in a little further without damag-
ing the joint, before trying to drive it out.
-==
rll
"S.
To remove strongly anchored femoral nails, another possibility ....e
"CC
-=
is to use the extraction hook. The correct size hook (see mark-
ings) is screwed into the connector. The assembly is then pushed =
rll
through the nail, and hooked on the distal end, avoiding the slot. =
e
Q,l
The ram guide is screwed onto the proximal end of the connec-
tor, the ram slid on, and the flexible grip attached. With blows
against the flexible grip the hook may force the nail out.
-==
...
....
r ll
!)()
If none of the described attempts at removal has been success- :.5

·;
ful, the only recourse may be the following: A longitudinal saw z
cut is made in the full thickness of the cortex down to the nail, C'
.!
=e
throughout the whole length of the diaphysis. This will allow the
bone to "spread" slightly, and reduce its grip on the nail. "CC
Q,l
-=
...
.s
309
•
6.12.6 The Unreamed Tibial Nailing System
Medullary nailing of shaft fractures of the lower extremity has

long proven its value, especially with the introduction of ream-
ing, and later interlocking. However, studies in recent years
I show that, embolisation of marrow into the major blood vessels
! in conjunction with reaming of the medullary canal may cause

pulmonary compromise, especially in multiple system trauma.
In fractures with extensive soft tissue damage and in open frac-
tures grade I, II or, IliA, the reaming procedure causes addi-
tional trauma to the already impaired blood supply,and nailing
has not been the method of choice. The introduction of a solid
nail with a small diameter has made it possible to treat these in-
juries with nailing but without reaming. The locking possibility
ensures axial and rotational stability.
Current experience has also shown that treating open fractures
with a solid nail is a good alternative to external fixation. A solid
nail does not present the relatively large dead space of a hollow
nail where bacteria may thrive and increase the risk of infection,
The UTN finds application in fresh fractures of the diaphysis of
the tibia; closed with extensive soft tissue damage, or open
grade I, II, or IliA. The unreamed nail is especially to be consid-
ered in multifragmentary/segmental fractures, if the bone is
covered or can be covered with viable soft tissue within a few
days of nailing. Furthermore, there must be no sign of infection
already present at the fracture site.
Treatment with the unreamed nail may be temporary or defini-
tive. The indication can be extended to some fresh fractures of
the proximal and distal diaphysis if the locking bolts permit suf-
ficient hold in the peripheral fragment, and do not compromise
the proper internal fixation of any associated intra-articular ex-
tension.
Note: The UTN is designed for use with interlocking only. Con-
traindications are ongoing infections, poor bone stock, patho-
logical fractures, mal unions, and non unions.
Because of the small diameter of both the nail and the locking
bolts, excessive load on the implants must be avoided, or else
they may undergo fatigue failure. Weight-bearing exceeding
"'
Q,l 15 kg must be avoided; in bony defects and segmental com-
&
'i: minution, toe-touching is the limit. Increase of weight-bearing
"5 depends on clinical and radiological progress to healing.
~ In some cases, for example poor patient compliance, the un-
-== reamed nail may later be exchanged for a larger diameter
=
~
reamed universal nail. This is done once soft tissue healing is as-
-=e
.9
"!U sured, and limb vascularity is good.
Q,l
-....c=
"'
• 310
6.12.6.1 Instruments for the UTN
The instruments for the insertion of the UTN can be obtained in

either a graphic case or a sterilising tray.
Centring Pin, 4 mm Diameter, 400 mm

This pin is connected with the universal chuck and introduced
about 50 mm into the medullary canal at the point of insertion,
and at the correct angle. It is used to guide the cannulated cutter.

This chuck is used to insert the centring pin.
Cannulated Cutter, 11 mm Diameter, 350 mm

This cutter is used together with the centring pin to open the
medullary canal. The centring pin can be fixed with the Allen
screw. The cannulated cutter has a special sharpened tip to al-
low cutting/carving while rotating the instrument 180 ° by hand
and then turning back. Some older instruments have a metal
plate at the end of the handle, inviting use of the hammer, but
this is not recommended, since damage to the cortex and to the
delicate cutting edge may result. The cutting edge may be re-
sharpened.
Protection Sleeve for the Cannulated Cutter

This sleeve is used to protect the soft tissue when opening the
medullary canal.
Measuring Rod
This measuring rod is 550 mm long and is used to determine the
length of the UTN. A radiographic ruler has recently been de-
veloped.
311 •
Coupling Block with Round Sleeve
This block is used for insertion of the UTN, together with the in-
sertion handle and the connecting bolt. The longer lip of the
proximal end is positioned over the bevelled end of the nail. The
marking indicates the end of the nail. The diameter of this end
does not exceed the nail's cross-section in diameter, making in-
sertion less critical. The notches of the distal end connect the in-
sertion handle for either the left or the right leg.
Coupling Block with Square Sleeve

This block may also be used for insertion of the UTN together
with the insertion handle and the connecting bolt. The proximal
end is fitted over the nail end so that the marking corresponds to
the contour ofthe nail end. The use of this coupling block for the
insertion assembly permits use of greater transverse force on
the nail end, which may facilitate reduction.
Connecting Bolt
This bolt is passed through the insertion handle and the cou-
pling block before being screwed into the upper end of the nail
using the combination wrench. It should be firmly but not exces-
sively tightened. This assembly is then used for insertion of the
nail.
Insertion Handle for UTN, 8 mm and 9 mm Diameter

For insertion of the UTN, the handle is connected to the cou-
pling block and secured in correct position before tightening the
connecting bolt in the nail end. The handle is placed laterally for
insertion if this gives better access, depending upon any soft tis-
sue lesion. For locking, the insertion handle must be placed on
the medial side The insertion handle is used for proximal static,
or dynamic locking (see markings).
Insertion Handle, 45 o for UTN

This handle is used if the fracture is in the proximal diaphysis,
and locking of one of the diagonal holes is necessary. The handle
'~> is attached to the regular insertion handle with the lugs engag-
&
a.~
ing the notches of the regular insertion handle. The connecting
] bolt is tightened in the nail end, and the knurled nut used to lock
:! the handle.
~
"C
=
--=
~
=
·=
~
Knurled Nut
e
Q,j
-.sc
' I)
This nut is used to fix the 45 o insertion handle in position.
• 312
Inserter- Extractor for the UTN
This piece is screwed onto the distal end of the connecting bolt,
and used with the slotted hammer for insertion and extraction
oftheUTN.
Slotted Hammer
This hammer is used over the inserter - extractor to insert the
UTN by gentle blows.
Combination Wrench, II mm
This wrench is used to tighten the connecting bolt in the nail end.

This trocar is inserted into the protection sleeve, 11 mm/8 mm,
and the assembly positioned in the appropriate hole in the inser-
tion handle to determine site for the proximal locking bolts.
Protection Sleeve, 11 mm/8.0 mm Diameter

This sleeve fits into the holes in the insertion handle, and is used
to guide the drill sleeve 8.0 mm/3.2 mm, the depth gauge, and
the screwdriver.
Drill Sleeve, 8.0 mm/3.2 mm Diameter

This sleeve fits in the protection sleeve 11 mm/8 mm, and is used
when drilling for the proximal locking bolt with the 3.2 mm drill
bit.
Drill Bit, 3.2 mm Diameter, Three-Fluted

This drill bit, 215 mm/190 mm, has a quick coupling end. It is
used to pre-drill for the locking bolt 3.9 mm. The depth mark-
ings at 25- 100 mm, in 5 mm increments, allow determination of
the screw length, but only when the 8.0 mm/3.2 mm drill sleeve
is used as its guide.
Hexagonal Screwdriver for 3.9 mm Diameter Locking Bolts

This screwdriver has a tip which is 2.5 mm wide across the flats
to fit the 3.9 mm locking bolts. The shaft has a groove to accom-
modate the large screw-holding sleeve, and a small handle to
prevent too much force from being exerted.
313
•
This is a self-retaining screw-holding sleeve, necessary to hold
and to allow traction when locking bolts are removed. It consists
of three parts and must be disassembled for cleaning.
6.12.6.2 The UTN and Locking Bolt, 3.9 mm
The UTN is a solid nail made of cold-worked implant steel. Its

surface has been roughened to enhance fatigue life (see
Sect.6.1.1). The slightly flared proximal end has a diamond-
shaped cross-section, which at the anterior end is bevelled to
prevent damage to the patellar ligament. The bend of the nail
forms an angle of 9 o, conforming to the anatomy of the tibia
when correctly inserted.
The proximal end has two mediolateral locking holes ; one
round for static and one elongated for dynamic locking. Further,
there are two holes for diagonal locking at 45 o each to the
frontal plane for additional anchoring of fractures in the proxi-
mal diaphysis. The round holes are 4 mm in diameter. Locking
of the nail provides axial and rotational stability.
The threaded cannulation of the proximal end accepts a sealing
screw, which can be inserted after locking, and left in place to
prevent ingrowth of soft tissue.
The distal two thirds are straight, with a cross-section corre-
sponding to a triangle with a semicircular posterior baseline.
The posterior tapered tip of the distal end guides the nail along
the posterior wall during insertion, reducing the risk of penetra-
tion of the cortex.
The distal end has two mediolaterallocking holes, and one be-
tween them in an AP direction.
At present the UTN is available in 8 mm and 9 mm diameters, in
lengths from 255 mm to 360 mm in 15 mm increments, and from
380 mm to 420 mm in 20 mm increments.
The Locking Bolt, 3.9 mm Diameter

This bolt has a core size of 3.2 mm and a shallow thread, which r, t'i'PC'iT · % 1 ~
should engage both cortices to prevent backing out of the screw,
"'~ and to facilitate removal of the bolt. The trocar tip is self-cut-
.:= ting, thus pre-tapping is not necessary. The low head profile is of
.a
~ advantage in areas with minimal soft tissue coverage. The
~ 8.0 mm head diameter allows use of the large screw-holding
=
"C
~
sleeve, which fits on the special screwdriver for 3.9 mm locking
...=
screws.
·=...
~
The 3.9 mm locking bolt is available in lengths from 22 mm to
= 64 mm, in 2 mm increments, and from 68 mm to 80 mm, in 4 mm
e
Q,j
.....=
increments.
.s"'
• 314
2.5
4 @ - Head diameter:
- Head height:
S.Omm
2.5mm
80
- Hexagonal socket width: 2.5mm
- Core diameter: 3.2mm
- Drill bit for pilot hole: 3.2mm
6.12.6.3 Insertion and Locking of the UTN
Supine Position on a Traction Table

This position allows only limited treatment of soft tissue in-
juries.
The knee of the injured leg is bent 90 ° over a well-padded
popliteal support, and extended obliquely downwards. A pad is
used to support also the distal femur at a sufficient distance from
the popliteal artery and vein (A and V).
Extension can be applied by a padded boot or by calcaneal trac-
tion. If distal locking is planned skeletal traction has to be used,
since the boot extends too far proximally and obstructs access to
the locking area.
The uninjured leg is placed in abduction, flexion and external
rotation at the hip to ensure free movement of the C arm of the
image intensifier in AP and mediolateral directions. Reduction
and correction of rotation must be carried out before sterile
draping, since it is difficult to adjust during surgery.
Supine Position on a Standard Table
-=
This position is recommended, especially for polytraumatised
patients, and for grade II and III open fractures in order to "'
ensure optimum soft tissue access. Reduction may be carried ~
-=e
Q..
out using the large distractor. The Schanz screws are inserted
in the frontal plane as close to both tibial ends as possible. A
-e
"C
radiolucent table is necessary for image intensification. The ~
knee is bent and held by an assistant during insertion of the "'

=
Col
--=
nail.
2
"'
!:)f)
Determining the Nail Length and Diameter
:5
·;
z
The length of the UTN can be determined by inserting the mea-
suring rod into the medullary canal under image intensification
~
.
.!
control.
The required length can also be determined, also under image
=e
"C
Col
intensification, by holding a UTN next to the tibial shaft. The

nail diameter is chosen by measuring the diameter of the
--=
f
315
•
medullary canal. Only 8 mm and 9 mm diameter nails are avail-
able. If the diameter is by any chance less than 8 mm the canal
must be reamed before insertion.
Point of Insertion p
The correct choice of the insertion point is essential for the suc- M
cess. As a general rule, the insertion point is in line with the long
axis of the medullary canal, slightly medial to the tibial tubercle,
and as proximal as possible without impinging on the anterior
lip of the tibial plateau.
A longitudinal incision is made over the patellar ligament in the
' line with the medullary canal. The tendon is split. A step by step
A
procedure is described below:
Opening the medullary canal:

- The 4 mm guide pin, held in the universal chuck with T han-
dle, is placed at the point of insertion at an angle of 9 o in the
sagittal plane. The UTN can be held alongside the tibia to act
as a guide. Its upper section indicates the correct angle. By si-
multaneously turning and pressing the universal chuck, the
pin is inserted into the medullary canal.
- The cannulated cutter with protection sleeve is pushed over
the guide pin and used to cut open the cortex and enter the
medullary canal. The cutter is turned 180 o by hand and then
turned back. It should follow the direction of the guide pin,
making a channel in the same axis as the upper end of the im-
plant.
- The guide pin and cannulated cutter are removed.
- The coupling block, the insertion handle and the connecting
bolt are assembled and tightened in the chosen nail, using the
combination wrench. Excessive tightening must be avoided.
The lugs of the handle must engage the notches of the cou-
pling block. For insertion, the handle may be fixed either lat-
erally or medially; for proximal locking the handle must be
placed medially.
"' Insertion of the nail:
& - The inserter - extractor is tightened on the connecting bolt,
~
] and the nail assembly inserted manually as far as possible.

~ - The slotted hammer is used to seat the nail gently. If any res is-
-= tance is felt, the nail should never be forced into the me-
; dullary canal, but changed to a smaller size. The nail is insert-
= ed until the etched mark on the coupling block is flush with
·=........
~
anterior surface of the tibia. The entire length of the nail is
e= then in the tibia. If inserted beyond the mark the coupling
~
.,-..=
block may jam or the bone may split.
' I;
c - The slotted hammer and the inserter- extractor are removed.
• 316
Distal Locking of the Nail Using Radiolucent Drive
In general, distal locking is performed first. If necessary, the dis-

tal fragment can then be manipulated using the insertion han-
dle. The use of the radiolucent drive allows control of drilling
under image intensification, and ensures that the surgeon's
hands remain outside the main radiation field.
- The image intensifier is adjusted until the most distal hole is
clearly visible and appears completely round.
- A stab incision is made.
- The tip of the 3.2 mm three-fluted drill bit, connected to the
radiolucent drive, is positioned over the centre of the hole.
- The radiolucent drive is adjusted until the drill bit appears as
a dot in the centre of the hole and of the centring ring.
- After centring the drill bit exactly, both cortices are drilled
under image intensification. Note: Drilling must not start un-
til position of drill bit is exact.
- The depth gauge is used to measure the length.
ed. This is necessary to ensure that the trocar tip is outside the
bone, and the thread is engaging the entire far cortex.
- A second, and, if necessary, a third locking bolt is inserted us-
ing the same procedure.
Distal Locking Using the Distal Aiming Device
Distal locking can be performed using the distal aiming device

employed for locking of the universal nails. A fixation bolt for
the direction finder is not available, therefore the aiming proce-
dure has to be repeated for the second locking bolt. The tech-
nique is the same as described for the universal nails, except that
the 3.2 mm drill bit and 3.9 mm bolt are used; seep. 304.
Distal locking can also be performed using "free-hand tech-
nique".
317 •
Proximal Locking
Proximal locking is performed by using the insertion handle as a

guide. The insertion handle must be placed medially for the
locking procedure.
into the "static" hole of the handle and pushed through a stab
incision in the soft tissue onto the bone (Fig.l ).
- After removing the trocar the 8 mm/3.2 mm drill sleeve is in-
serted. The 3.2 mm three-fluted drill bit is used to drill both
cortices (Fig. 2).
- The length is measured with the depth gauge (Fig. 3). 2
ed. This is necessary to ensure that the tip is outside the bone,
and the thread is fully engaging the far cortex (Fig. 4).
- The second locking bolt is inserted through the "dynamic"
hole of the insertion handle, using the same technique as de-
scribed above (Fig. 5).
- After loosening the connecting screw with the combination
wrench, the insertion instruments are removed (Fig. 6).
- The sealing screw is inserted in the proximal end of the nail to 3
prevent ingrowth of soft tissue, thereby facilitating nail re-
moval (Fig. 7).
"'
QJ
=
Q"'
·=
-=Col
~
"C
=
=
--=
=
·==
QJ
6
-==
...
"....'
7
• 318
Dynamisation of the UTN
By inserting the locking bolt in the elongated hole using the in-
sertion handle as a guide for correct placement, fractures of the
types A1-3 , B1-3, and C2 may be primarily dynamised. The
main fragments must be in direct contact to prevent shortening.
Secondary dynamisation within 6-10 weeks by removing the
"static" locking bolt may be considered in certain fracture .
Proximal Locking Using the 45 o Insertion Handle
If the fracture is in the proximal diaphysis, it may be necessary

to lock the nail by using one of the diagonal holes.
- The 45 o insertion handle is attached to the regular handle and
locked in the desired position with the locking nut.
- The diagonal locking bolt is inserted using the same tech-
nique as described above.
6.12.6.4 Instruments for Insertion and Locking of the UTN
See illustrations.
-"'=
-
~
"S.
e
"Cl
=
-
~
"'
e=
--==
~
I
...
"'
l:)tl
:5
·;
z....
...
.!
'3
"Cl
e
--
~
...
~
=
319
•
6.12.6.5 Instruments for Removal of the UTN
- The locking bolts are removed through stab incisions using

the hexagonal screwdriver and the large screw-holding sleeve
to exert traction.
- The nail end is cleared of tissue, and the sealing screw re-
moved using the hexagonal screwdriver.
- The coupling block for extraction and the connecting screw
are attached to the nail end using the combination wrench for
tightening.
- The inserter - extractor is screwed onto the end of the con-
necting screw, and light blows from the slotted hammer used
to extract the nail by gentle blows.
6.13 External Fixator Devices:

Instruments and Implants
External fixation has been used since the last century to stabilise
displaced fractures. Only with the development of mechanically
sound devices has external fixation offered a reliable alternative
to internal fixation in complex fractures. Several devices exist;
some consisting of numerous components making them difficult
to apply. Others are heavy in weight and cumbersome for the
patient. The AO/ASIF tubular system is lightweight, consists of
few components only and provides suffcient versatility and sta-
bility for successful treatment, also of most problem fractures
where internal fixation is indicated.
"'iiJ Indications :
·a= - Stabilisation and correction of extremity malalignment and
-5 length discrepancies in severe open fractures and infected
~ non unions
"Cl
=
=
- Initial stabilisation of bony disruption and soft tissue injuries
--===
.~
-
-
in polytraumatised patients
Closed fractures with associated severe soft tissue damage
Multifragmentary diaphyseal and periarticular lesions
..-e=
iiJ
- Certain pelvic ring disruptions
- Arthrodesis
...."'
= - Compression fixation in osteotomies
• 320
6.13.1 The Large External Fixator- Tubular System
The large external fixator - tubular system can be obtained in

sterilising trays or in aluminium cases. Graphic cases are being
developed. Both stainless steel tubes and radiolucent carbon fi-
bre rods are available.
6.13.1.1 Standard Instruments, Implants,

and Fixation Components

This bit, two-fluted, 195 mm/170 mm, with a quick coupling
end, is used to drill the pilot hole for the 5.0 mm Schanz screw
with radial preload. It is also used to drill the near cortex if the
4.5 mm Schanz screw with the 18 mm thread is to be inserted
and for both cortices when the Steinmann pin, 5.0 mm in diame-
ter, is to be applied. The 4.5 mm drill bit is used with the drill
sleeve 6.0 mm/5.0 mm.

This drill bit, two-fluted, 195 mm/170 mm, with quick coupling
end, is used to drill the pilot hole for the 5.0 mm Schanz screw
with a core size of 3.5 mm. It is also used to drill the far cortex
before inserting the 4.5 mm Schanz screw with 18 mm thread
length, and to drill both cortices for the Steinmann pin, 4.5 mm
in diameter. The 3.5 mm drill bit is used with the 5.0 mm/3.5 mm
drill sleeve.
Triple Drill Sleeve Assembly, 110 mm

The triple drill sleeve assembly is employed as drill sleeve and
tissue protector if the soft tissue is deep.lt is also used if a double
tube configuration is planned, where the drill sleeve assembly
has to be long enough to pass through two sets of clamps and still
321
•
reach the bone. The length of the drill bit may then have to be
adapted.
- The trocar, 3.5 mm in diameter, 110 mm long, used together
with the two drill sleeves, helps to penetrate the soft tissue af-
ter the incision has been made.
- The drill sleeve, 5.0 mm/3.5 mm in diameter, accepts the tro-
car, 3.5 mm in diameter, and the drill bit, 3.5 mm in diameter.
- The drill sleeve, 6.0 mm/5.0 mm, is the outermost drill sleeve
of the assembly. It accepts the other two components and is
used separately as drill sleeve for the 4.5 mm drill bit and for
insertion of the Schanz screws, 4.5 mm and 5.0 mm in diame-
ter. The sleeve fits the adjustable clamp and remains in the
clamp until the Schanz screw has been inserted.

The 80 mm triple drill sleeve assembly is employed as drill
sleeve and tissue protector where there is little depth of soft tis-
sue (tibia). It can be inserted in the clamp and used as drill sleeve
for single tube configurations, with short distances between
clamp and bone.
- The trocar, 3.5 mm in diameter, 80 mm, used with the other
two drill sleeves helps to penetrate the soft tissue after the
stab incision has been made.
- The drill sleeve, 5.0 mm/3.5 mm, accepts the trocar, 3.5 mm,
and the drill bit 3.5 mm in diameter.
- The drill sleeve, 6.0 mm/5.0 mm, is the outermost drill sleeve
of the assembly. It accepts the other two components and is
used separately as drill sleeve for the 4.5 mm drill bit and for
insertion of the 4.5 mm and 5.0 mm Schanz screws. This
sleeve fits the adjustable clamp and remains in the clamp until
the Schanz screw has been inserted.
D epth Gauge for Schanz Screws
The depth gauge is used to determine the the length of insertion

1 \)
of the Schanz screws. After drilling both cortices the depth
gauge is inserted through the 6.0 mm/5.0 mm drill sleeve and
hooked on the far cortex. The knurled disc is moved onto the top
of the drill sleeve, tightened with the screw, and the depth gauge
"'~ removed. The Schanz screw which has been selected is tightened (
·=' in the universal chuck with T handle at the distance indicated by

.E~:.~ the depth gauge, between the hook and the knurled disc.
~
a
"C
=
Q The combination wrench is used to tighten the nuts on the
~ clamps and the open compressor.
=e
Q,l
-.s.=
"'
• 322
Socket Wrench
This wrench, 11 mm in width across flats , is also employed for
tightening nuts on the clamps or the open compressor.

The chuck is used to insert the Schanz screws or Steinmann pins.
By turning the T handle clockwise the jaws close. For releasing
the pin the upper part of the chuck is pulled back and the handle
turned anticlockwise.
Implants for the Tubular System
Schanz Screw, 5.0 mm Diameter, for Radial Preload

The 5.0 mm Schanz screw for radial preload is a newly devel-
oped screw, which may be the implant of choice for the external
fixator in the future. The blunted trocar tip is self-cutting. The
core size of the screw, which is only slightly larger than the drill
hole of 4.5 mm, allows the screw to exert radial preload. This has
shown to significantly reduce pin loosening and pin track infec-
tion. The screw has demonstrated good strength in relation to a
force acting perpendicular to the long axis.
Schanz Screw, 4.5 mm Diameter

The 4.5 mm Schanz screw has a 3.5 mm diameter core, 18 mm
thread length, and a slightly rounded off trocar tip. This screw
provides good purchase in cortical bone. The threaded portion
engages the far cortex after pre-drilling with the 3.5 mm drill bit.
The stiff 4.5 mm shaft has a tight interference fit in the near cor-
tex in the 4.5 mm drill hole. This enhances the rigidity of the
frame by placing the large diameter (4.5 mm) shaft within the
near cortex where bending forces are the highest.
The 4.5 mm Schanz screw is available in lengths from 100 to 250 -=
"'
-
~
mm, in 25 mm increments. "S.
e
-
Schanz Screw, 5.0 mm Diameter "C
=
~
The 5.0 mm Schanz screw, with a 3.8 mm core and 50 mm thread "'
=
--.
length, has a slightly rounded off trocar tip to prevent damage to e
~
the soft tissue. Since part of the threaded portion with the 3.8 =
mm core remains outside the bone, the screw is less stiff an im- =
"'
-
plant than the screws presented above. ~
These screws, core size 3.8 mm diameter, thread length 50 mm, Q
~
are inserted in the two main fragments , and connected to the ~
~
..=
distractor. They are used in lengths 150, 175, and 200 mm. -;
~
~
~
323
•
Fixation Components
Stainless Steel Tubes, II mm Diameter

These tubes are the longitudinal stress-bearing elements. The
stainless steel tubes are highly corrosion resistant and provide a
safe and strong frame. They are light and add little weight to a
frame configuration. The grooves at each end were originally
meant to keep the plugs in place, which were used formerly to
prevent the clamps from slipping off the tube during initial as-
sembly. These plugs have now been replaced by the protective
caps.
The tubes are available in lengths from 100 to 450 mm, in 50 mm
increments, and also lengths of 550 and 650 mm.
Carbon Fibre Rods, II mm Diameter

Carbon fibre rods are also used as longitudinal stress-bearing el-
ements, and have the advantage of being radiolucent. They are
approximately 30% stiffer and 40% lighter than the stainless
steel tubes. The rods are manufactured from carbon fibre-rein-
forced epoxy. They have a special coating, which provides in-
creased protection against fibre damage when clamps are tight-
ened. The coating also improves the friction properties between
the clamp and the rod, and eliminates moisture penetration dur-
ing autoclaving.
The carbon fibre rods are available in lengths from 100 to 600
mm in 50 mm increments.
Connecting Bar, 5 mm Diameter

The connecting bar of stainless steel is used to connect two
frames to increase the stiffness. It is connected by using two ad-
ditional clamps, e. g. open clamps.
The bar is available in lengths from 100 to 300 mm, in 50 mm in-
crements.
Adjustable Clamp
The adjustable clamp is the basic clamp connecting 4.5 mm or
5.0 mm Schanz screws or Steinmann pins to the tube or the car-
~ bon fibre rod. The clamp permits screw or pin insertion for an-
g. gle adjustments over 15 o in the frontal plane. The rectangular
·a grooving of the vice plate assembly accepts the triple drill sleeve
'5
~ assembly, allowing drilling and insertion of a screw or pin
-c through the clamp. The vice plate is identified by a ring and the
; number 6. Older vice plates had no markings and must be re-
-e=
=
.~
.S
placed before the triple drill sleeve assembly can be used.
The different parts of the adjustable clamp may be replaced as
necessary.
tl= Note: The clamp is not suitable for use with 6.0 mm screws or
.S pins .
• 324
Tube-to- Tube Clamp
The tube-to-tube clamp is used to connect one tube or rod to an-
other. It is tightened with one bolt only; the serration on the
clamp bodies, however, provide a safe lock.
Open Clamp
The open clamp may be added to a frame configuration already
built, to connect further Schanz screws to the tube or rod. It can
also be used to connect two unilateral frames with a connecting
bar. The open clamp does not permit any range of motion of the
pins in the plane of the tube's long axis.
Universal Joint for Two Tubes

The universal joint can also be used to connect two tubes or
rods. It consists of two clamp bodies and one intermediate piece
and can be mounted with the bodies beside each other or in op-
position.
The range of motion is limited and is less versatile than the tube-
to-tube clamp.
Transverse Clamp
The transverse clamp, 90 mm long, connects the tube or rod
with two Schanz screws placed in the transverse plane without
limiting pin angulation or distance between pins. This results in
greater control and improved stability of relatively short, meta-
physeal fragments.
The clamp may be used in proximal and distal tibial fractures or
in ankle arthrodesis. It is also used in segmental bone transport
and bone lengthening procedures. Seep. 334.
Open Compressor
The open compressor may be used for compression or distrac-
tion. It is placed on the tube with the plate in the closed position
and adjacent to a clamp. Its attachment nut is tightened. The
tube-holding nut on the clamp is loosened and the combination
wrench or the socket wrench used to turn the nut on the open
compressor. It then exerts pressure on the clamp causing move-
ment on the Schanz screw. Before removing the open compres-
sor the tube-holding nut on the clamp must be tightened.
Caps for Tubes and Rods

The caps, made of a sterilisable plastic material, fit on the ends
of the tube and rod to prevent the clamps from slipping off dur-
ing initial assembly and application.
325
•
Drill Bits, 3.5 mm and 4.5 mm, Three-Fluted

The 3.5 and 4.5 mm drill bits are of great advantage when
drilling for the Schanz screws.The three cutting edges minimise
the tendency for the drill bit to skid off the bone surface, even
when drilling at an acute angle. The drill bits may be used with
the oscillating attachment. These drill bits have quick coupling
ends only. See Sect. 6.3.1.
Oscillating Attachment
The oscillating attachment, which is used with the small air drill,
converts the rotation of the drill bit into oscillating movements
(270 °). The oscillation prevents spooling of soft tissue around
the drill bit, reducing the risk of neurovascular or other damage.
The attachment is locked in place over the top trigger of the
small air drill, preventing activation of the reverse gear. Only
drill bits with a quick coupling end can be used. By pushing the
collar forward the drill bit is inserted and turned until fully seat-
ed. The collar is then released.
Simple Handle
The handle is for insertion of Schanz screws and Steinmann
pins. The locking screw may be tightened by hand or by the
hexagonal Allen key.
Bolt Cutter Assembly

The handles for the bolt cutter, 13 mm and 24 mm, 460 mm long,
are used together with the bolt cutter heads, 4.5 mm diameter
and 5.0 mm diameter to shorten Schanz screws or Steinmann
pins of corresponding diameters.
6.13.1.3 Additional Instruments for Segment Transport

and Bone Lengthening
Threaded Rod, 8mm Diameter

The rod is assembled with the components listed below, as well
as with transverse and adjustable clamps and used for segmental
bone transport and bone lengthening.
The threaded rod is available in lengths from 250 to 450 mm, in
50 mm increments .
• 326
,-::;; Nuts, 11 mm, for Threaded Rod 8 mm Diameter
' These nuts are used to lock the transport tubes on the threaded
rod.
Transport Tubes, 11 mm Diameter

These tubes are fixed on the threaded rod with a nut at each end,
and accept the clamps connected to the Schanz screws in seg-
ment transport and bone lengthening procedures. Three
lengths are provided: 60, 80, and 100 mm.
Transport Nut
The nut screwed on the threaded rod is used to move the trans-
port tube.lt has indentations, which when turned in increments,
each accomplished by a "click", cause a segment displacement
of0.2mm.
6.13.1.4 Additional Instruments and Implants for Bilateral

Frame Configuration
A bilateral frame configuration may be applied, for example, in

arthrodesis of the knee or ankle.
Aiming Device Assembly

The aiming device is used for accurate placement of the third
and fourth Steinmann pin in a bilateral frame configuration.
The hook is fixed on the measuring bar by the locking screw.
The locking sleeve is slid on the measuring bar in the direction
indicated by the arrow on top of the carriage. The measuring bar
holds the hook and the locking sleeve, forming a "C". The check
tube is used to align the hook and sleeve.
When drilling the pilot hole for the third Steinmann pin, the
hook is first fitted in the clamp on the opposite side of the bone.
The 110 mm long 5.0 mm/3.5 mm drill sleeve and the 110 mm
trocar are tightened in the locking sleeve. The locking sleeve is
then slid on the measuring bar and pushed onto the bone
through the near clamp. The drill bit, 3.5 mm, can now be used
to drill for the Steinmann pin. See also Sect. 6.20.
Steinmann Pins, 4.5 mm and 5.0 mm Diameter

The Steinmann pins, with trocar tip, slightly rounded off, are
used for bilateral frame construction with the tubular system,
when the pin has to be inserted through the bone. The pins are
inserted by hand using the universal chuck or the simple handle,
but never with a power maschine, since this would cause thermal
damage and increase the risk of pin loosening and pin track in-
fection.
327 •
The pilot hole is drilled with the 3.5 mm drill bit for the 4.5 mm
pin and with the 4.5 mm drill bit for the 5.0 mm pin.
Steinmann pins are available in both stainless steel and titanium
alloy in lengths from 125 to 300 mm (see SYNTHES catalogue
for details).
Protective Caps, 4.5 mm and 5.0 mm Diameter

The protective caps are used if the Schanz screw or Steinmann
pin is cut, to cover the sharp end.
6.13.1.5 Considerations When Applying the External Fixator
Depending on the indication for external fixation, different

biomechanical, anatomical, and technical aspects have to be
considered before deciding on the frame configuration. By us-
ing only a few elements a great number of different frames can
be built to achieve the necessary stability.
Frame Stiffness and Fracture Stabilisation of Long Bones

Clinical and experimental evidence have shown that the stiff-
ness of a tubular frame can be increased and motion at the frac-
ture site diminished by the following:
- Placing the main frame in the sagittal plane.
- Increasing the distance between the Schanz screws in each
main fragment (Fig. 1).
- Pre loading the Schanz screws by pre-drilling 4.5 mm and us- 2
ing the 5.0 mm Schanz screws with 4.6 mm core size (radial
preload). Other Schanz screws can be preloaded to a certain
extent by applying tension to the screws. This may be done by
the open compressor, a reduction forceps, or by hand (Fig. 2).
- Increasing the number of Schanz screws in each main frag-
3
ment.
- Reducing the distance between the bone and tube.
- Using a "double tube" frame.
- Increasing the distance between the tubes.
- Applying a two-plane unilateral frame (Fig. 3).
"'
~
6- Preloading of Schanz Screws and Steinmann Pins

·=
'5 By applying preloading tension between pairs of screws and
~ pins, micromovement between the cortical bone and the
-=; screw/pin is minimised. The risk of bone resorbtion around the
--==
.::= screws, loosening and possible pin track infection is thereby re-
duced. Seep. 27.
e
~
--==
...
"'
• 328
Schanz Screw Insertion in the Tibia
Taking the "safe corridor" into consideration when determining
the site for Schanz screw insertion and using the oscillating at-
tachment for pre-drilling help in avoiding injury to the main ves-
sels, nerves, and musculotendinous units. The placement of the
frame must also be planned such that it does not interfere with
wound access. This may be necessary for initial debridment, or
for secondary procedures, such as transfer of soft tissue flaps,
sequestrectomies, or the placement of a bone graft.
6.13.1.6 Application Techniques

of the Large External Fixator- Tubular System
Application of a Unilateral, One-Plane Frame- Single Tube

Using Schanz Screws, 4.5 mm with an 18 mm Thread
A single tube unilateral frame may be applied for the stabilisa-

tion of open fractures grade II and III with minimal bone loss.
Note: The Schanz screws with radial preload can also be used. In
this case only the 4.5 mm drill bit is used to drill the pilot hole.
- The fracture is grossly reduced before applying the fixator.
- After stab incision, the triple drill sleeve assembly is pushed
through the soft tissue onto the bone and positioned at right
angles to the long axis. This first Schanz screw should be in-
serted close to the joint (Fig.l).
- The trocar is removed, and the 3.5 mm drill bit used to drill
both cortices (Fig. 2).
329
•
- The 3.5 mm drill sleeve is removed, and the 4.5 mm drill bit
used to drill the near cortex (Fig. 3).
- The depth gauge is pushed through the 4.5 mm drill sleeve
and hooked on the far cortex. The knurled disc is moved onto
the top of the drill sleeve and its screw tightened (Fig. 4).
- The Schanz screw of appropriate length is tightened in the
universal chuck with the T handle at the distance indicated
with the depth gauge (p. 322). It is then inserted through the
drill sleeve until the chuck abuts the top of the drill sleeve
(Fig.5).
- A long enough tube is prepared with at least four adjustable
clamps and caps at each end. The most distal clamp is fixed on 3
the Schanz screw (Fig. 6).
7 9
- Axial and rotational alignment of the fracture is checked. The

triple trocar is pushed through the most proximal clamp and
positioned at right angles to the long axis of the bone. The 3.5
mm drill bit is then used to drill through both cortices (Fig. 7).
- The 3.5 mm drill sleeve is removed and the 4.5 mm drill bit
used to drill the near cortex (Fig. 8).
- The length is measured with the depth gauge (Fig. 9).
- The second Schanz screw is inserted (Fig.lO).
- Before tightening the clamps on the tube, proper length and
rotational alignment must be secured. T he clamps are tight-
ened with the combination wrench or socket wrench. 10
• 330
- The third and fourth Schanz screws are inserted through their
respective clamps, one in each main fragment. They are
placed near the fracture, but leaving at least 2 em between the
screws and the fracture area. The same technique of insertion
as was described for the second screw is used (Fig.11 ).
- The screws should be preloaded one by one by bending the
11
pair of screws in each main fragment towards each other.
Preload can be achieved by using the open compressor, a for-
ceps, or by hand. The nut fixing the adjustable clamp on the
tube is loosened and the clamp with the Schanz screw placed
under tension. The nut is retightened.
Application of a Unilateral, One-Plane Frame- Short Tubes,

and Tube-to-Tube Clamp
The application technique is similar to the one described above,

but the Schanz screws may be applied in different planes before
reduction. The screws in each main fragment are connected
with short tubes. Each of these tubes is then connected by a
tube-to-tube clamp to an intermediate connecting tube. Align-
ment changes are easily made after loosening the two joints con-
necting the intermediate tube to the other two tubes.
Application of a Unilateral, One-Plane Frame- Double

Tubes, Using Schanz Screws, 5.0 mm, with Radial Preload
Two tubes stacked on top of each other for unilateral fixation in-
crease the stiffness of the frame. This may be needed in frac-
tures with large areas of comminution or bone loss.
- The fracture is grossly aligned.
- After stab incision, the long triple drill sleeve assembly is
pushed through the soft tissue onto the bone at right angle to
the long axis (Fig.l).
- The trocar and the 3.5 mm sleeve are removed and the 4.5
mm drill bit used to drill through both cortices (Fig. 2).
331
•
- The depth gauge is pushed through the 4.5 mm drill sleeve
and hooked on the far cortex. The knurled disc is moved onto
the top of the drill sleeve and its screw tightened (Fig. 3).
- The 5.0 mm Schanz screw, with radial preload and of appro-
priate length, is tightened in the universal chuck with T han-
dle at the distance indicated by the depth gauge. It is inserted
through the drill sleeve until the chuck abuts the drill sleeve
(Fig.4).
- Two tubes are prepared with at least four adjustable clamps 9
on each and caps at the ends. The Schanz screw is fixed to the
two tubes with adjustable clamps (Fig. 5).
- The fracture is reduced manually and axial and rotational
alignment checked. In the most proximal pair of adjustable
clamps the long triple drill sleeve assembly is inserted. It is
pushed through the stab incision onto the bone (Fig. 6).
- After removal of the trocar and the 3.5 mm drill sleeve the 4.5
"'~ mm drill bit is used to drill through both cortices (Fig. 7).
·a - The length is measured (Fig. 8).
-5 - The second 5.0 mm Schanz screw with radial preload is tight-
~ ened in the universal chuck with T handle at the measured 10
-== distance. It is inserted through the drill sleeve until the chuck
--
~
.::= abuts the top of the sleeve (Fig. 9).

- Before tightening the clamps on the tube, proper length and
~
= rotational alignment must be secured. The clamps are tight-
..e"'
~
--
ened with the combination wrench or socket wrench.
= - The third and fourth Schanz screws are inserted through their
= respective pair of clamps, one in each main fragment. They 11
• 332
should be placed near the fracture, but leaving at least 2 em
between the screws and the fracture area. The same tech-
nique is used as described for the second screw (Figs.10, 11 ).
Application of a Unilateral,
Two Plane Frame - V-Shaped Frame
The stiffness of the frame can be increased by adding a second

unilateral frame and then interconnecting the two frames. The
technique of application is the same as described for the single
tube frame (see above). The ventral frame is first applied in a
nearly sagittal plane, slightly medially. The second unilateral
frame is applied on the medial aspect at an angle between 60 o
and 100 o with the first frame. Two or four Schanz screws are
used for each frame. The two long tubes are then interconnect-
ed by adding connecting bars fixed with open clamps.
Dynamisation of a Unilateral Frame- Double Tubes
It appears that bone formation is stimulated by progressive

force transmission at the site of the consolidated fracture. After
soft tissue healing partial, and later full, weight-bearing induces
the force transmission. This may also be achieved by gradually
building down the rigidity of the fixator frame or through dy-
namisation.
Dynamisation of a double-tube unilateral frame is obtained by
crosswise release of the tube nuts. All Schanz screws must be in
the same plane to permit longitudinal gliding.
Bone Segment Transport and Bone Lengthening
A technique for bone lengthening and segment transport after

corticotomy has been introduced by Ilizarov. It is employed in
segmental defects or length discrepancies of more than 3-4 em.
The elongation procedure starts 5- 7 days after percutaneous
corticotomy performed with an osteotome. Through gradual
elongation over a period of time, the callus "stretches" to bridge
the gap. The surrounding soft tissue, nerves, arteries, veins, and
skin also lengthen during distraction. The elongation is accom-
plished by small frequent increments up to 1 mm per day, which
causes the patients less pain and fewer neurological symptoms
and circulatory problems than single-step increment.
The AO/ASIF double-tube frame combined with a few addi-
tional components can be applied to perform the elongation.
333
•
Step by step procedure (segment transport):
- A long enough tube is prepared with a transverse clamp (A),
and at least five adjustable clamps. Protective caps are ap-
plied at each end. A threaded bar of corresponding length is
prepared with three short tubes fixed with nuts (C). The prox- A
imal tube carries a transverse clamp and an adjustable clamp,
locked in position with a nut at each end. The other two tubes
are fitted with two adjustable clamps (E). The nut at one end
of the central (transport) tube is the transport nut (D) (Fig.1 ).
- A Schanz screw, 5.0 mm is inserted distally in the distal seg-
ment. A second 5.0 mm Schanz screw is inserted in the proxi-
mal segment about 2 em proximal to the planned corticotomy
site (A). In the metaphysis 5.0 mm Schanz screws are chosen.
When a transverse clamp is used for the metaphyseal frag-
ment the two Schanz screws are inserted later.
- The rod and tube prepared with the clamps are connected to
the two Schanz screws. The clamps are stacked immediately
on top of each other. Any deformities are corrected. The rod
and tube must lie exactly parallel to the bone axis.
- Two 4.5 mm Schanz screws are inserted as far apart as possi-
ble into the planned transport segment distal to the corticoto-
my site. One 4.5 mm screw is inserted proximally in the distal
segment. At least 2 em must remain between the screws and
the ends of the segments (B).
- Two 5.0 mm Schanz screws are inserted through the trans-
verse clamp. For easy access the transverse clamp is posi- 2
tioned so that the pin-clamping nuts face proximally and the
tube-clamping nut faces anteriorly.
- The corticotomy is performed in the metaphyseal - diaphy-
seal junction. Three-quarters of the circumference is cut with
a sharp osteotome through a small skin incision. The cut is
completed by twisting the segments in opposite directions to
fracture the bone. It is verified by turning the transport nut
with the combination wrench and advancing the segment
1 mm (five "clicks") (C) (Fig. 2).
- The Schanz screws are cut with the bolt cutter approximately
1 em above the clamps, and the ends covered with protective
caps.
- The progressive elongation starts after 5-7 days.
"'~ - The tube nuts of the two adjustable clamps on the outer (non-
.&
2 threaded) tube affixed to the transport segment Schanz
'5 screws are removed. The transport nut is turned with the
~ combination wrench from one indentation to the next, which
] moves the segment in increments of 0.2 mm. Five turns daily
=Q
give the desired 1 mm elongation (Fig. 3).
i - Partial weight-bearing is recommended during the transport 3
=e period.
-..=..=
~
- In segment transport procedures a cancellous onlay graft is
placed over the "docking" area as soon as there is contact be-
"' tween the transport segment and the distal fragment.
• 334
- The transport tube is now locked to the threaded rod by tight-
ening the nuts at both its end.
- The nuts which were previously removed from the adjustable
clamps on the outer tube are replaced and tightened. This
"locks" the whole assembly to allow distraction regenerate to
consolidate and the docking zone to unite. This process usual-
ly takes at least as long as the transport took.
Note: Close attention must be paid to the screw/pin sites during
the course of lengthening. Signs of reddening must be carefully
cleaned and covered and a short course of systemic antibiotics
or an enlargement of the screw/pin entry site with a scalpel un-
der local anaesthesia. A loose screw must be removed and a new
one inserted at another site.
Leg lengthening is performed in similar manner, with only two
Schanz screws in the distal fragment.
Application of a Bilateral Frame in Arthrodesis

and Corrective Osteotomies
The tubular external fixator may be used for various arthrode-

ses and corrective osteotomies, where symmetrical compres-
sion at the osteotomy site is mandatory. This is best achieved by
c::::;on===l~l==on== a bilateral frame. Depending upon the site and the compression
needed, the stability of the one-plane bilateral frame is en-
hanced by a second plane frame. Compression by prestressing
the pins, which also helps prevent pin loosening, is achieved by
using open compressors. The size and number of pins in each
fragment depends on the size of bone and type of fixator. Pre-
planning by drawings of the planned osteotomy and insertion
sites of the different pins is essential.
t The technique of application differs from procedure to proce-
dure and can not be described in detail. For further information
see Manual of Internal Fixation. (Muller et al.1991).
Step by step procedure for insertion of Steinmann pins and ap-
plication of a bilateral frame:
- Through a stab incision the triple drill sleeve is pushed
through the soft tissue onto the bone at the site of the first
Steinmann pin.
- The trocar is removed and the drill bit, 3.5 mm (preferably
three-fluted), used to drill through both cortices. A stab inci-
sion is made at the opposite side for the protruding drill bit.
- A 4.5 mm or 5.0 mm Steinmann pin is inserted with the uni-
versal chuck with T handle through the 5.0 mm drill sleeve.
- The second Steinamnn pin is inserted in similar manner in the
opposite fragment, parallel to the first.
- Two tubes or rods are fitted with two or four adjustable
clamps each and caps at the ends. The Steinmann pins are
connected to the two tubes with the adjustable clamps and all
nuts tightened slightly.
335
•
- If a second Steinmann pin in one or both main fragments is to
be inserted, the aiming device is used. The hook of the assem-
bled aiming device is inserted in the adjustable tube clamp on
the far side of the bone, then the locking sleeve with the tight-
ened 3.5 mm drill sleeve is pushed through the near clamp.
This permits drilling a 3.5 mm hole into which the Steinmann
pin can be inserted in correct alignment with the two clamps.
To facilitate insertion of the pin, the hole may be overdrilled
with the 4.5 mm drill bit (three-fluted) after the 3.5 mm
sleeve has been removed.
Note: If Steinmann pins are inserted in the metaphyseal area,
they may be better placed parallel in the horizontal plane and
connected by a transverse clamp.
- After insertion of the Steinmann pins, compression at the os-
teotomy site is achieved by the use of open compressors. The
pins in each fragment are prestressed one after the other. An
open compressor in closed mode is attached at the end of the
two tubes with the plate adjacent to the adjustable clamp.
- The tube nuts of the adjustable clamps are opened. Using the
combination wrench or socket wrench the bolts of the open
compressors are turned simultaneously, exerting pressure on
the clamps and moving of the attached Schanz screws. The
tube nuts of the clamps are retightened and the open com-
pressors removed.
- The compression procedure is repeated for each Steinmann
pin in the same manner.
- Protective caps are used to cover the sharp tips of the pins.
6.13.1.7 Instruments for the Application and Removal

of External Fixators
Instruments for application of a tube to tube - unilateral exter-

nalfixator
• 336
Instruments for application of a double tube or V-shaped unilat-
eral external fix a tor
Instruments for application of an external fixator for segment

transport and bone lengthening
-=
"'
-=
!OS
"S.
e
-e=
"C
!OS
"'
Instruments for removal of the large external fix a tor
--==..
~
"'
..
-=
~
0
~
~
-;
..=
0
~
-
~
~
337
•
6.13.2 The Small External Fixator
For the stabilisation of open fractures grade II and Ill, or of

complex fractures with defects, in the distal forearm, the small
external fixator may be applied instead of the large fixator. Dis-
traction ofthe wrist joint is thus possible. Experience has shown
that the length of the radius, restored by closed reduction, and,
if possible, percutaneous pinning, can be maintained by distrac-
tion due to pull of the intact capsular ligamentous complex, so-
called "ligamentotaxis". The small external fixator may also be
applied to stabilise fractures in small bones, while treating soft
tissue injuries.
Indications:
- Unstable fractures of the distal radius; wrist or hand
- Metaphyseal/epiphyseal comminution
- Metaphyseal comminution with loss of substance and
marked dorsal tilt (Co lies) or with radial shortening
- Fractures with volar tilt (Smith), or with volar intra-articular
fragment (reversed Barton)
- Open fractures
- Multifragmentary fracture in combination with other frac-
tures of the upper extremity, or injuries of the hand
- Fracture dislocation of the wrist joint
- Intra-articular comminuted fracture of the base of the first
metacarpal
- Complex injuries of the hand where skeletal stabilisation is
not otherwise possible
6.13.2.1 Instruments and Implants
"' A set of instruments and implants for the application of the

&
~
small external fixator is obtainable in a sterilising tray or a small

] aluminium case.
(.I
~
"C
;
--==
.~
~
e
~
.s-
2
"'
• 338
Drill Bit 2.0 mm Diameter
This bit, 100 mm/75 mm, two-fluted and for quick coupling, is
used to drill for the 2.5 mm Kirschner wire with threaded tip in
hard bone or for Kirschner wires used for fixation of fragments.
The triple wire guide, 2.0 mm, is used as a drill guide.

The triple wire guide is used as a drill sleeve for the 2.0 mm drill
bit or for parallel placement of Kirschner wires.
,. 0Z
Double Drill Sleeve, 2. 7 mm/2.0 mm
~
The double drill sleeve can be used as a guide when drilling with
the 2.0 mm drill bit and to protect tissue when inserting the 2.5
mm Kirschner wire with thread.
Small Triple Drill Sleeve Assembly, 4.0 mm

Similar to the large triple drill sleeve assembly (see Sect.
6.13.1.1), a small drill sleeve assembly is being developed to be
used with the clamps, 4.0 mm for the small external fixator. It
consists of three parts:
- The trocar, 2.1 mm, is used with the two drill sleeves to pene-
trate soft tissue.
- The drill sleeve, 2.1 mm/2.7mm, accepts the trocar and the
drill bit, 2.0 mm, necessary for pre-drilling for the Kirschner
wire with threaded tip, 2.5 mm.
- The drill sleeve, 2.7 mm/4.0 mm, with handle is the outermost
sleeve accepting the drill sleeve, 2.1 mm/2. 7 mm, and the tro-
car, 2.1 mm. It fits in the 4.0 mm clamps and remains in the
clamp until the Kirschner wire with threaded tip, 2.5 mm, has
been inserted.
Kirschner Wires with Threaded Tip, 2.5 mm, 150 mm

The Kirschner wires are inserted in the index metacarpal in a
very small radius , functioning as implants to connect the clamps
with the bars. The wires may be inserted by power either straight-
away or after pre-drilling with a 2.0 mm drill bit. The thread por-
tion should rermain in the far cortex to ensure good purchase.
Kirschner Wires, 1.6 mm and2.0 mm Diameter, 150 mm

The wires are used for percutaneous fixation of intra-articular
fractures . Pre-drilling the hard cortex may sometimes be neces-
sary. Kirschner wires are inserted with the small air drill
equipped with Jacobs chuck using the triple wire guide.
Kirschner wires are available in other sizes, too. See SYNTHES
catalogue.
339
•
Schanz Screw, 4.0 mm Schaft and 3.0 mm Thread Diameter
The Schanz screw, 80 mm long, may be used for insertion in the
radius instead of the Kirschner wires. The 20 mm thread length
ensures a good purchase in the bone. Pre-drilling with the 2.5
mm drill bit is necessary before inserting the Schanz screw by
hand with the simple T handle or the universal chuck with T
handle.
Clamp, with Pear-Shaped Hole, 4.0 mm

Recently developed, the clamp with the pear-shaped hole is
used to connect both Schanz screws, 4.0 mm in diameter, and
Kirschner wires with a threaded tip, 2.5 mm in diameter, to the
4.0 mm tube. Thanks to the pear-shaped hole, screws and wires
with diameters between 2.5 mm and 4.0 mm can be used. They
are fixed with the 7 mm nut. This clamp replaces the two clamps
4.0 mm/4.0 mm and 4.0 mm/2.5 mm.
Open Clamp with Pear-Shaped Hole, 4.0 mm

The open clamp can be added to the 4.0 mm bar to connect an
additional screw or wire after the frame has been built. Thanks
to its pear-shaped hole pins 2.5 mm- 4.0 mm in size can be con-
nected. This clamp replaces the two open clamps described be-
low.
Clamp, 4.0 mm/2.5 mm

The clamp is used to connect a 4.0 mm bar to the Kirschner wire
with thread, 2.5 mm.
Clamp, 4.0 mm/4.0 mm

The clamp is similar to the 4.0 mm/2.5 mm clamp, but connects
two 4.0 mm connecting bars or one bar to a Schanz screw, with
4.0 mm shaft.
"'
~
6- Open Clamp, 4.0 mm/4.0 mm

·a
-=
1:,1 This clamp can be used to complete a 4.0 mm bar to bar connec-
~ tion after the frame has been built.
"CC
=
co:
.:....= Open Clamp, 4.0 mm/2.5 mm
....
co:
This clamp connects an additional 2.5 mm Kirschner wire with
e= threaded tip to the 4.0 mm bar in a prebuilt frame.
~
..
....=
.s"'
• 340
Spring-Loaded Nut
The spring-loaded nut is used for temporary tightening of the
clamps but is not intended for use over a longer period of time,
since the holding power decreases over time.
Small Open Compressor

The compressor is used to prestress the screws or wires to pre-
vent loosening and pin track infection. It is applied in closed
mode on the 4.0 mm connecting bar or rod with the plate adja-
cent to the clamp. Tightening the screw with the socket wrench
moves the clamp and its attached wire in the desired direction.
Combination Wrench, 7 mm, and Socket Wrench, 7 mm

The combination and socket wrenches are used to tighten the
nuts of the clamps.
Connecting Bars, 4.0 mm Diameter, in Stainless Steel

The connecting bars are used to build the frame of the small ex-
ternal fixator. They are available in lengths from 60 to 200 mm,
in 20 mm increments.
Carbon Fibre Rods, 4.0 mm Diameter

The carbon fibre rods are radiolucent and stiffer than the stain-
less steel rods. They are made of carbon fibre reinforced epoxy -=
"'
-
~
and have a special coating which provides increased protection "S.
against fibre damage when clamps are tightened. The coating e
"C
-=e
also improves the friction properties between the clamp and the ;
rod and eliminates moisture penetration during autoclaving. "'
The carbon fibre rods are available in lengths from 60 to 200
--==..
~
mm, in increments of 20 mm.

"'
~
Q
~-
lo<i
~
";j
E
~
-
lo<i
~
341 •
6.13.2.2 Application Technique of the Small External Fixator
Application of the small external fixator will obviously depend

upon the type of fracture and the condition of the soft tissue. An
unstable fracture of the distal radius is used as an example here.
- The patient lies supine and the injured extremity is positioned
horizontally on a radiolucent table. A tourniquet is generally
applied.
- The fracture is manually reduced. Intra-articular fractures
are fixed with percutaneous Kirschner wires using the small
air drill with Jacobs chuck. Open reduction may be needed in
severely displaced or impacted articular segments (Fig.l).
- Two incisions are made over the index metacarpal, radial to
the extensor tendons.
- Two 2.5 mm Kirschner wires with threaded tips are inserted,
with or without pre-drilling with the 2.0 mm drill bit (Fig. 2).
The wires should converge at an angle of40° to 60° in the ver-
tical plane (Fig. 3), without the points touching each other,
and at 45 ° to the horizontal plane. The metacarpo-phalangeal
joint is flexed to a right angle to avoid the extensor hood. The
converging wires have a longer passage through the bone,
and thereby a better hold. 2
- With the hand in pronation two incisions are made over the
dorsoradial aspect of the radius, 1-2 em long, and separated
by a distance of 4-6 em. The bone surface is exposed by blunt
dissection, protecting the superficial branches of the radial
nerve.
- The 2.5 mm drill bit is used to drill both cortices at 45 o angles
in the horizontal plane, and at 90 o in the vertical plane. A cor-
responding drill sleeve is used to protect the soft tissue 3
(Fig.4).
- The 4.0 mm/3.0 mm Schanz screw is inserted with the univer-
sal chuck with T handle or the simple T handle. Two Schanz
screws are inserted (Fig. 5). Image intensification is used to
confirm that the thread of the screws or wires remain in the
bone.
- If 2.5 mm Kirschner wires with threaded tips are used, they
may be inserted directly using the small air drill with the J a-
cobs chuck or after pre-drilling with a 2.0 mm drill bit through
the triple wire guide in the same direction as described above.
- The two Schanz screws are connected with the two 4.0 4
mm/4.0 mm clamps on the connecting bars. If double bars are
used for increased stability of the frame, both bars have to be
connected at the same time.
- Similarly, the two Kirschner wires are connected to the dou-
ble bars with 4.0 mm/2.5 mm clamps. All nuts are tightened.
• 342
- The four bars may now be connected with two 4.0 mm/4.0
mm clamps (Fig. 6). These clamps are not fully tightened.
- Final reduction by distraction is performed and the intercon-
necting clamps tightened while the wrist is being held in the
desired position.
The stability of the fixation may be increased by prestressing the
screws or wires by hand towards each other in each fragment.
The small open compressors may also be used.
Note : Four short bars may also be connected by two intermedi-
ate bars and four 4.0 mm/4.0 mm clamps.
Note: If one or two long bars are used, the two outer Kirschner
wires or screws have to be connected to the clamps before
drilling and inserting the two inner wires or screws through the
corresponding clamps.
6.13.2.3 Instruments for Application

of the Small External Fixator
Since different frame configurations are possible it is recom-

mended that the complete sterilising tray or aluminium case be
available for all applications. Additional Schanz screws may
have to be added to the instrumentation.
6.13.2.4 Instruments for the Removal

of the Small External Fixator
The small external fixator frame is removed by disconnecting

the clamps using the 7 mm socket wrench or combination
wrench. The Kirschner wires may be removed by using the small
air drill in reverse motion. Schanz screws are removed with the
universal chuck with T handle.
6.13.3 The Pinless Fixator
The large pinless fixator has recently been developed to provide

temporary fixation in open or closed tibial fractures with major
soft tissue injury. The fixation of the device to the bone is guar-
anteed by clamps inserted in the cortex only if the medullary
cavity is not penetrated.
The risk of pin track infection with possible medullary contami-
nation is excluded. The pinless fixator provides a reliable con-
struct to protect the soft tissue in preparation for a secondary,
final mode of fixation. A small size pinless fixator is being devel-
oped for use in forearm fractures.
343
•
Indications:
- Open or closed fractures with severe soft tissue damage in
multiply injured patients whose prognosis for survival is un-
certain
- Open tibial fractures (grade Illc) with uncertain prognosis as
to limb survival
- Open or closed tibia fractures, with or without soft tissue le-
sions, associated with severe cerebral damage
- Emergency fixation of tibia fractures in war surgery and mass
casualties
The pinless fixator has also been used for skeletal traction.
6.13.3.1 Instruments
These instruments are:

- Pin less clamps with posts
- Handgrip
- Adjustable clamps (from external fixator tubular system)
- Stainless tube or carbon fibre rod (from tubular system)
- Combination wrench, 11 mm in width across flats
6.13.3.2 Application Technique

- Provisional reduction of the fracture.
- Insertion of two pinless clamps in each main fragment. The
trocar points of the clamps are pressed into the cortical sur-
face by squeezing the handgrip and at the same time rotating
backwards and forwards about the axis between the points.
- Attachment of the posts to the pinless clamps.
- Assembly of adjustable clamps to the posts.
- Connection of the four clamps by means of a tube or rod of
appropriate length.
- Reduction of the fracture components with all the clamps in
loosened positions.
- Tightening of all clamps to achieve the desired stability at the
fracture site.
"'~ See also Injury, AO/ASIF Scientific Suppl23 [Suppl3].
C"'
·a
-5
-=~ 6.13.4 The Lengthening Apparatus
;
=
-
·=-;
S
5
The small and the large apparatus with their one-dimensional
configuration and great stability were originally developed for
gradual leg lengthening of the upper and, especially, the lower
-;::2 extremities. Lengthening may be indicated in juvenile patients
.S with congenital or acquired shortening of a limb. Lengthening
• 344
of more than 20 em has been accomplished with the aid of this
apparatus. The healing process requires many months; only
very cooperative patients and a considerate, attentive and dili-
gent surgeon should involve themselves in this type of surgical
programme. The apparatus may also be used for fracture treat-
ment, where unilateral fixation is desired.
The mini-lengthening apparatus is used in peripheral lengthen-
ing procedures.
6.13.4.1 Large and Small Lengthening Apparatus,

Large and Small Lengthening Apparatus

0
The large apparatus is used in the lower extremity and the small-
~"'''!;':::::·:......... .. er one in the upper extremities. For femoral lengthening the ap-
paratus is applied on the lateral aspect, for tibial lengthening on
the antero-medial aspect.
The lengthening apparatus consists of two rectangular telescop-
ing tubes made of anodised aluminium.
Relative movement of the tubes is produced by an internal
threaded rod operated by a knob at one end. Notches on the
knob indicate the distance of movement; one notch corre-
sponds to 0.37 mm movement on the large apparatur and 0.33
mm on the small one.
Each fixation head can hold two Schanz screws for fixing the ap-
paratus to the bone. Both heads can be swiveled about each
-
locking nut in the long axis, and the upper part can be rotated for
angle correction in the frontal plane. The locking nuts are tight-
ened with the 11 and 14 mm ring wrenches. The apparatus has to
be disassembled for cleaning. See also Chap. 6.22.4.2.
Angled Piece, Large

By replacing the vice plate on the fixation head, the Schanz
screws can be placed at 90 a to the long axis of the large appara- -=
"'
-
c..
~
tus. It can then be used for rotational corrections.
e
-
=
Angled Piece, Small "C
~
Similarly, the vice plate of the small apparatus can be used in-
="'
stead of the small angeled piece to achieve the above mentioned
.e
--
~
screw placement. =
="'
.
-
Drill Bit, 3.5 mm Diameter [,;
0
The bit, 195 mm/170 mm, with a quick coupling end, is used to ~
~
pre-drill the pilot hole for the Schanz screws, 6.0 mm. It is used fZ
-;
-
with the drill sleeve, 6.0 mm/3.5 mm.
E
~
~
1-'l
345
•
The bit, 195 mm/170 mm, with quick coupling end, is used to
pre-drill the pilot hole for the Schanz screws, 4.0 mm. It is used
with the 4.0 mm/3.2 mm drill sleeve.
Drill Sleeve, 6.0 mm/3.5 mm

The sleeve, 110 mm, is used with the 3.5 mm trocar to advance
through the soft tissue onto the bone surface. After removal of
the trocar, the sleeve is used to guide the 3.5 mm drill bit.

The trocar is inserted in the drill sleeve, 6.0 mm/3.5 mm, to pen-
etrate the soft tissue before drilling for the 6.0 mm Schanz
screw.

The drill sleeve, 60 mm, is used with the 3.2 mm trocar to ad-
vance through the soft tissue onto the bone surface. After
removal of the trocar the sleeve is used to guide the drill
bit,3.2mm.

The trocar is inserted in the drill sleeve, 4.0 mm/3.2 mm, to pen-
etrate the soft tissue before drilling for the 4.0 mm Schanz
screw.
Ring Wrench
The ring wrench, 11 mm or 14 mm in width across flats , is used
to tighten the locking nuts of both the small and the large length-
ening apparatus, respectively.
Universal Chuck with T H andle

The universal chuck is used to insert the Schanz screws.
"'~ Schanz Screws, 6.0 mm Diameter

="'
] The 6.0 mm Schanz screws with flat point are used for the appli-
~ cation of the large apparatus. The thread length is 50 mm and
'C the core size 4.0 mm. Pre-drilling 3.5 mm is necessary before in-
§ serting the screw with the universal chuck with T handle.The
--e
c
.S flat point facilitates insertion of the screw.
~
c
Schanz Screws, 4.0 mm Diameter
=
!: The 4.0 mm Schanz screws with flat point are used for the appli-
.S"' cation of the small lengthening apparatus. The thread length is
• 346
25 mm and the core size 2.8 mm. The 3.2 mm drill bit is used for
pre-drilling before inserting the screw with the universal chuck
with T handle.
6.13.4.2 Application Technique of the Large Apparatus

in the Femur

- Through a stab incision, two to three fingerwidths above the
lateral condyle, the drill sleeve, 6.0 mm/3.5 mm, with trocar,
3.5 mm, is pushed through the soft tissue onto the bone sur-
face.
- After removal of the trocar the drill bit,3.5 mm, is used to drill
through both cortices parallel to the knee joint and centrally
located in the AP plane.
- A 6.0 mm Schanz screw is inserted using the universal chuck
with T handle.
- Using the same technique, a second Schanz screw is inserted
in the proximal metaphysis, about 1.5 em distal to the innomi-
nate lateral tubercle of the greater trochanter. The screw
must be parallel to the first screw.
- The lengthening apparatus is placed on the anterior side of
the screws to leave sufficient skin area for the subsequent
postero-lateral approach to the femoral shaft.
- The drill sleeve with trocar is inserted through the second
hole of the fixation head. It is then pushed through a stab inci-
sion and the soft tissue until it abuts the bone surface. This en-
sures that the Schanz screws in each fragment will be parallel.
The procedure is repeated through the second fixation head.
Two Schanz screws are then inserted in each fixation head.
- A postero-lateral insicion is made and a transverse osteotomy
or corticotomy performed between the Schanz screws.
- The apparatus is lengthened until stabilisation is achieved by
soft tissue tension. Drainage, wound dressing, and an elastic
bandage is applied.
- Lengthening by turning the knob one revolution per day (1.5
mm), in increments, may be performed by the patient. Active
motion of the knee joint and partial weight-bearing accompa-
ny the lengthening process. Careful attention must be paid to
the site of the screws. Any soft tissue pressure against the
screws must be avoided. Enlargement of the incisions may be
necessary.
- In children, spontaneous regeneration of the bone may occur
at the distraction site. When the desired length is reached,
and sufficient bony integrity is radiographically confirmed,
the knob of the lengthening device is turned in reverse and a
compressive load applied. The device is left in place until the
normal diameter of the bone has been reconstituted and the
intramedullary canal becomes visible.
347
•
- In the majority of cases internal fixation and bone grafting are
performed once the desired distraction has been achived. A
long enough plate (broad lengthening plate) is contoured and
applied on the postero-lateral aspect of the bone.
- If there is avascular scar tissue between the bone ends, bone
grafting is necessary. Grafts are taken from the posterior iliac
spine.
- After wound closure the apparatus is removed.
6.13.4.3 The Mini Lengthening Apparatus
For lengthening procedures in small bones, e. g. metacarpals,

the mini lengthening apparatus is attached to the main frag-
ments by 2.5 mm diameter Kirschner wires with 15 mm thread-
ed tips or by 2.7 mm cortex screws. The end vice plate may be
positioned longitudinally or transversely. Its position is adjusted
with the small hexagonal screwdriver.
One spindle revolution is equivalent to 0.7 mm lengthening

(from notch to notch approximately 0.23 mm ). The combination
wrench, or socket wrench, 7 mm is used for tighetening the nuts.
The apparatus may also be used as a reduction aid or as an exter-
nal fixator in small bones.
The apparatus must be disassembled for thorough cleaning.

The telescoping sleeve is fully extended and the vice plate re-
moved.
~ .,;.. - :: l!,o;;;iiiiiiiiiiiiiiiiiiiii
!
6.13.5 The Unifix
The Unifix is a unilateral external fixator which can be applied

in tibial and femoral fractures. The body is made of titanium al-
loy and provides high strength at low weight. Compressible ball
and socket joints permit a wide range of movement (25 °) of the
Schanz screws. The distance between the outermost holes is 225
mm, which is the limit for the application of the Schanz screws.
Correction of axial, lateral, and rotational displacements are
possible. Both compression and distraction can be achieved
with the Unifix, as can dynamisation.
• 348
6.13.5.1 Instruments, Implants, and Fixation Components
The Unifix and the instruments and implants can be obtained in

a sterilising tray.
Instruments

This bit, 195 mm/170 mm, two-fluted, with quick coupling end,
is used with the small air drill to drill the pilot hole for the
Schanz screws.
Drill Bit ,4.5 mm Diameter

The 4.5 mm drill bit, 180 mm/165 mm, two-fluted, for Jacobs
chuck, is used if a small air drill with quick coupling chuck is not
available.

The drill sleeve is used when drilling for the two innermost
Schanz screws.

The trocar and the drill sleeve, 6.0 mm/4.5 mm, are inserted
through the aiming device and the Unifix ball joint to determine
the stab incision site.
Aiming Device
This device is used when drilling for the second parallel Schanz
screw in each fragment. The holes in the aiming device match
those of the clamp section.
Simple Handle
The simple handle is used to insert the Schanz screws. The
Schanz screw is locked in place by the side screw.
349 •
Combination Wrench, II mm
The combination wrench is used to tighten and loosen the nuts
and the locking bolts.
Hexagonal Allen Key with Pin =(~J= \ ::::A Q....,.,......- ~ ~~-1=();:.

- - ~-~ ' - - -
The hexagonal Allen key is used to tighten and loosen the inter-
nal hexagonal bolt of the Unifix.
Implants
Schanz Screw, 6.0 mm Diameter

This 6.0 mm Schanz screw, for Unifix, has a roughened shaft sur-
face to increase its durability. See Sect. 6.1.1. The screw has a
core size of 4.8 mm, thread length of 50 mm, and a blunted tro-
car tip. The 4.5 mm drill bit is used for pre-drilling.
The screws are inserted with the simple handle. They are avail-
able in lengths of 125, 150, and 175 mm.

The 6.0 mm Schanz screws, with a core size of 4.1 mm, a thread
length of 50 mm, and a flat point, may be applied in cancellous
bone after pre-drilling with a 3.5 mm diameter drill bit. They are
available in lengths of 130,160, and 190 mm.
Fixation Components
Unifix
The U nifix consists of:
- Two clamp sections, with three 11 mm hexagonal nuts each
- Four Unifix ball clamps
- One central component with knurled compression bolt
- One locking bolt
- Six internal fixation bolts with nuts
High grade alloys are used in the manufacture of the individual
"' parts and so they need no maintenance. Lubricants can even im-
~ pair the stability of the Unifix.
·s
Q"
-=
(,I
~ 6.13.5.2 Application Technique

"C
=
=
= Depending on the localisation the Unifix it is prepared with, or
-e=
0
~ without, its central component. It is initially used in a straight
~
position with tightened hinge joints so that it can act as a tem-
-.s..=
plate.
cr.
If the central component is used, it should be in its middle posi-
tion, allowing for either compression or distraction .
• 350
- The fracture is preliminarily reduced and the fixator position
determined.
- The drill sleeve, 6.0 mm/4.5 mm, and trocar are inserted
through the stab incision.
- The pilot hole for the Schanz screw is drilled perpendicular to
the long axis of the bone using the 4.5 mm drill bit.
- The first 6.0 mm Schanz screw is inserted using the simple
handle.
- The Unifix is placed onto the first screw and tightened by
hand.
- The drill sleeve and trocar are pushed through the end ball
joint on the other side of the fracture and a stab incision
made.
- The 4.5 mm drill bit is used to drill for the second Schanz
screw.
- The 6.0 mm Schanz screw is inserted with the simple handle.
- The aiming device is mounted on one of the screws. The drill
sleeve with trocar are inserted through the second hole of the
aiming device and the corresponding ball joint.
- After a stab incision and drilling 4.5 mm, the third Schanz
screw is inserted.
- The second Schanz screw in the other main fragment is insert-
ed using the same technique.
Note: Secondary correction of alignment is possible without dis-
assembling the Unifix. All nuts have just to be loosened and
retightened after correction. The following operations are pos-
sible:
- The locking bolt in the central component is loosened.
- Distraction with the central component is achieved by turn-
ing the knurled compression bolt.
- Axial, lateral and rotational displacements are corrected by
loosening the six hexagonal nuts and retightening them after
manipulation.
- Compression of the fracture is achieved by turning the
knurled compression bolt. The Unifix then automatically ad-
justs from the initial straight position to a slightly angulated
shape. Nuts are then all tightened.
Further Possibilities
Shortening:
- The central component can be removed by opening the two
hinge joints.
- The two main components can then be fitted together direct-
ly.
- The shortened Unifix is secured by using one of the internal
hexagonal bolts from the central components.
- The bolt is loosened in a clockwise direction and tightened in
an anticlockwise direction as it is fitted with a left hand thread.
351
•
Additional Rotation
Further rotation than that which is possible with the ball and
socket joints may be achieved by loosening the locking bolt in
the central component. Rotation of another 35 o is then possi-
ble. Note that longitudinal guidance of the locking bolt is only
maintained when placed in the groove. If rotated, compression,
distraction, or dynamisation is not possible.
6.13.5.3 Instruments for Removal of the Unifix
The Unifix is removed by loosening all the nuts with the 11 mm

combination wrench. The Schanz screws are removed using the
simple T handle, or even better the universal chuck with Than-
dle.
6.14 The Distractor
The distractor is a reduction instrument for temporary use in

simple or complex fractures. It offers the possibility of distrac-
tion or compression by controlled movement of the fragments.
After insertion of the selected implant, the distractor is re-
moved. A large and a small distractor are available.
6.14.1 The Large Distractor
The large dis tractor is of sufficient dimension to allow applica-

tion of considerable force and is used for gentle open or closed
reduction of fractures of femur and tibia, upper extremity,
pelvis, and acetabulum. In many cases it serves as an alternative
to positioning the patient on a fracture table. It may also be ap-
"' plied to facilitate reduction of complex intra-articular fractures,
~ or even in arthroscopic surgery such as meniscus repair. It al-
]=" lows rotational control and correction in any plane about one or
c.J more axes. It is applied to the bone by Schanz screws.
-= Its predecessor, a simple model, fixed to the bone by special con-
~
; necting bolts, only allowed rotational correction up to 30 °. Its
§ versatility is therefore limited, but may still be useful in selected
-e=
"-; cases.
~
-.se
'11
• 352
6.14.1.1 Instruments, Implants, and Distractor Components
The distractor components, the instruments and the implants

can be obtained in a sterilising tray.
Standard Instruments

This bit, 195 mm/170 mm, two-fluted, with quick coupling end,
is used to drill the pilot hole for the 5.0 mm Schanz screws. The
110 mm triple drill sleeve assembly is used as drill sleeve .
...........................................-.-~"11 Triple Drill Sleeve Assembly, 110 mm

This sleeve is employed as the drill sleeve and tissue protector
for the 3.5 mm drill bit. It consists of three parts:
- Trocar, 3.5 mm diameter, 110 mm, used together with the two
drill sleeves, helps to penetrate the soft tissue after the inci-
sion has been made.
- Drill sleeve, 5.0 mm/3.5 mm, accepts the trocar, 3.5 mm diam-
eter and the drill bit, 3.5 mm diameter.
- Drill sleeve, 6.0 mm/5.0 mm, is the outermost drill sleeve of
the assembly. It accepts the other two components and is used
separately for insertion of the 5.0 mm Schanz screw.

This chuck is used to insert the Schanz screws manually.
Pin Wrench
This wrench can be employed to tighten the locking nuts.
Implants

These screws, core size 3.5 mm diameter, thread length 50 mm,
are inserted in the two main fragments, and connected to the
distractor. They are available in lengths 150, 175, and 200 mm.
...
Q
-
ti
f
< ll
353 •
Distractor Components
Threaded Rod, 14 mm Diameter

This rod is connected with the sleeve-holding bracket at one end
and the hole and the carriage at the other end. These parts are
locked in place with the locking nuts. Depending on the site for
the dis tractor, the 440 mm or the 330 mm rod is used.
Locking Nut
The locking nut is screwed on the rod and used to hold the car-
riage and the sleeve-holding bracket in place. The nuts on each
side of the carriage are turned to achieve distraction or compres-
sion. The pin wrench can be used to tighten or loosen the nuts.
Sleeve-Holding Bracket
This bracket is screwed on the end of the threaded rod, which
has a hole, and locked in its centre slot with the locking pin
through the hole of the rod. The long screw-holding sleeve is at-
tached after removal of the spring-loaded locking nut; the ser-
rated surfaces of the bracket and the sleeve should engage. The
nut is retightened. The sleeve-holding bracket allows connect-
ing to Schanz screws in different planes.
Carriage
This carriage is placed at the other end of the threaded rod and
locked in position by two locking nuts. After removal of the
spring loaded locking nut, the short screw-holding sleeve is at-
tached with the serrated surface engaging that of the carriage,
and the nut retightened. The carriage is connected to the distal
Schanz screw by this sleeve.
Screw-H aiding Sleeve, 105 mm

This sleeve is attached to the sleeve-holding bracket to hold the
Schanz screw in the proximal fragment. The Schanz screw is
fixed in the sleeve by the wing nut.
Screw-Holding Sleeve, 55 mm
"'
·a=
~
This sleeve is attached to the carriage to hold the Schanz screw

'5 in the distal fragment. The Schanz screw is fixed in the sleeve by
~ the wing nut.
'C
=
=
--==
.9=
e
-=..=
~
...."'
• 354
6.14.1.2 Additional Components for Use
with Universal Femoral Nailing System
See alsop. 288.
Curved Aiming Attachment

This piece is attached to the universal nail insertion handle.lt al-
lows proper placement of a 5.0 mm Schanz screw in the proxi-
mal femur in an antero-posterior direction, to which the upper
end of the large distractor is connected. The curved aiming at-
tachment accepts the 140 mm triple drill sleeve assembly and al-
lows drilling and insertion of the Schanz screw perpendicular to
the axis of the nail.
Manipulation Nail, 11 mm Diameter

This nail is connected with the universal nail insertion handle by
the locking nut. It is inserted in the medullary canal and may be
used for reduction or to indicate the nail axis, when placing the
proximal Schanz screw for the dis tractor.

This bit, 225 mm/200 mm, three-fluted, with quick coupling
end, is used with the 140 mm long drill sleeve assembly fitted
into the curved aiming attachment to drill for the proximal
Schanz screw, 5.0 mm.

This assembly is employed as the drill sleeve and tissue protec-
tor for the 3.5 mm drill bit, when using the curved aiming attach-
ment in the insertion handle It consists of three parts:
- Trocar, 3.5 mm diameter, 140 mm, used together with the two
drill sleeves, helps to penetrate the soft tissue after the inci-
sion has been made.
- Drill sleeve, 5.0 mm/3.5 mm, accepts the trocar, 3.5 mm diam-
eter and the drill bit, 3.5 mm diameter.
- Drill sleeve, 6.0 mm/5.0 mm, is the outermost drill sleeve of
the assembly. It accepts the other two components and is used
separately for insertion of the 5.0 mm Schanz screw.
6.14.1.3 Clinical Applications of the Distractor
Positioning of the patient:

- Any position on a standard operating table may be used.
..
Versatility in application:
-
=
- Schanz screws, 5.0 mm are inserted after pre-drilling 3.5 mm
-
1.1
(three-fluted drill bit is recommended) in each main fragment

f
perpendicular to the long axis of the bone. "'
Q
355
•
- The joints of the proximal sleeve-holding bracket and the
joint of the distal carriage permit simultaneous movement
about several axes and in any plane. The position of the
Schanz screws may thus alter according to the anatomical
situation.
- In open fractures, traction is normally sufficient for reduc-
tion. Generally, lateral dislocation and rotational deformity
can be corrected by simple traction applied by manipulation
of the distractor and by the use of reduction forceps.
- In closed fractures, lateral malalignment is often difficult to
correct. In addition to the axial force needed for traction, use
of the distractor permits the application of the necessary la-
teral forces via the Schanz screws inserted proximally and
distally.
- Use of the different joints permit derotation and displace-
ment of the main fragments so that they can then be fixed, or
even compressed, in the required position.
Intramedullary nailing:
- The distractor may be applied for reduction purposes instead
of positioning the patient on a traction table. Special aiming
instruments are necessary. For application technique see
Sect. 6.12.5.1.
Assembly and attachment of the dis tractor to Schanz screws:
- The short, or the long, threaded rod is selected. A locking nut
is screwed on each end.
- The sleeve-holding bracket is fixed in the straight position
and assembled with the long screw-holding sleeve. The ser-
rated surfaces should engage properly. The bracket is
screwed on the threaded rod end which has a hole until this
hole appears in its centre slot. The locking pin is pushed
through the hole to lock the bracket.
- The locking nut is tightened firmly against the bracket with
the pin wrench.
- The short screw-holding sleeve is secured to the end of the
carriage by the spring-loaded locking nut. The two serrated
surfaces should engage properly.
- The carriage is slid onto the threaded rod and secured at each
end of its barrel by a locking nut.
"' - The long screw-holding sleeve is slid onto the proximal
=-=
~
Schanz screw so that the axis of the threaded rod is parallel to

] the long axis of the bone. The wing nut is tightened to hold the
~
~ screw firmly.
"C
- The short screw-holding sleeve connected to the carriage is
=
=
= slid onto the distal Schanz screw. If necessary, the locking nuts
-==
0
·~ can be temporarily loosened. The wing nut is tightened to
hold the screw firmly. The locking nuts on the joints are firmly
~
-.s=
tightened.
...
"'
• 356
- Distraction is applied by loosening the outer and turning the
inner locking nut holding the carriage. To prevent torsion of
the fragments relative to each other, the Schanz screws are
held manually during distraction. Axial and rotational
malalignment may be corrected by adjusting the Schanz
screws held by universal chuck with T handle. The spring-
loaded locking nuts are tightened using the combination
wrench.
- When the end position is reached the outer locking nut is
fixed against the carriage.
6.14.1.4 Instruments for the Application

and Other Instruments
Instruments for the application of the large distractor
Additional instruments for the distract or for medullary nailing
6.14.2 The Small Distractor
The small distractor can be used for distraction and reduction of

fractures in small bones. The pin-holders that are mounted on
the carriage have two holes. In one hole the 2.5 mm Kirschner
wire with threaded tip is inserted and fixed with a screw. The
second hole may be used for a parallel Kirschner wire, or screw,
to prevent rotation of fragments if necessary. The connected
wires or screws are at right angles to the spindle, and no correc-
tions can be made with the pin-holders. The Kirschner wires ...
t:=
must therefore be parallel, and inserted at right angles to the
long axis of the bone. Excursions of 10-40 mm is possible.
-e
"'
Q
357 •
6.15 The Bone Forceps
Bone forceps of various sizes and design are available for reduc-
tion of fractures. Reduction of a fracture may be the most chal-
lenging part of internal fixation, especially in complex fractures,
and may greatly influence the result of the fixation. The primary
goal of reduction is to restore and maintain normal anatomy
with gentle, atraumatic technique, whilst preserving the vascu-
lar supply. In simple fractures manual reduction and application
of an appropriate reduction forceps may be easy. In complex
fractures both the reduction and the application of a reduction
aid may be of considerable difficulty. Knowledge of the anato-
my and of the function of the different reduction aids will facili-
tate the procedure. As a general rule, the size of the reduction
forceps must correspond to that of the bone. Using too small a
forceps or applying excessive force will damage the instrument.
Some large reduction forceps can be obtained as a set in a steril-
ising tray or in a graphic case. Reduction forceps for small and
mini fragments are described in Sects. 6.9.1 and 6.11.1.
Reduction Forceps with Points

These forceps, 160 mm and 200 mm, hold fragments reduced
with the two sharp points, which require little space, and still al-
low positioning of the definitive implant. The forceps are avail-
able with ratchet closure or a speed lock which can be swung
open. Even markedly separated bone ends can thus be reduced.
The speed lock can be operated with the index finger.
Reduction Forceps with Serrated Jaws

These forceps, 170 mm and 240 mm, have a speed lock, which
only allows limited opening of the serrated jaws. The forceps is
excellent for temporary retention of plates and fragments.
The speed lock is released by squeezing the handles and turning
the screws anticlockwise.
• 358
Self-Centring Bone-Holding Forceps (Verbrugge Pattern)
These forceps, 240 mm marked 1, 260 mm marked 2, and 280
mm marked 3, are three reduction forceps used for temporary
retention of fragments and plates in long bone fractures. The
self-centring jaws permit modification of the reduction and
holding function. The self-centring bone-holding forceps have a
speed lock which is easily operated with one hand. To release
the speed lock the handles are slightly squeezed and the screw
turned anticlockwise.
Patellar Forceps
These forceps, 175 mm, with double points, may be applied for
reduction of patellar fractures. The speed lock permits easy clo-
sure with one hand. To release the speed lock; see above.
Fibular Forceps, Straight and Bent

These forceps, 210 mm, are mainly used for reduction of fibular
fractures. The speed lock permits easy closure. Forceps of ear-
lier design had ratchet closure.
Malleolar Forceps
These forceps, 210 mm, with two points which meet at a 15 o an-
gle, may be applied for reduction of malleolar fractures.
Holding Forceps
These 210 mm forceps for tibial edge fragments have sharp
points allowing a secure grip of the fragment.
"'
..=-
~
(j
""'=
~
=
Q
359
•
Bone Spreaders
These pieces, 210 mm and 270 mm, have blade widths of 8 mm
and 12 mm, respectively. They may be of use to distract frac-
tures for cleaning of the fracture surface. They may also be used
as a distraction device. In this case, the spreader is placed be-
tween the end of a plate anchored in one main fragment, and a
screw that is placed free in the other main fragment approximat-
ing 1 em from the end of the plate. Opening of the bone spread-
er between the screw and the end of the plate provides a distrac-
tion force at the fracture site.
6.16 General Instruments for Bone Surgery
Some general instruments such as retractors and periosteal ele-

vators are available to facilitate the exposure of fractures. Some
of these instruments are contained in a sterilising tray or in a
graphic case. For instruments for small and peripheral bones
see Sects. 6.9.1 and6.11.1. See also SYNTHES catalogue.
Periosteal Elevators
These elevators with synthetic handles, approximately 200 mm
long, are available with straight or rounded blades of different
widths. The elevators are used for careful dissection, for atrau-
matic exposure of the fracture, and for cautious cleaning of the
fracture surfaces. The periosteum must not be stripped widely,
since this would damage the blood supply and possibly disturb
bone healing.
Retractors
Hohmann style retractors, of lengths between 220 mm and 270
mm, are available with blade widths of 8-70 mm, and with sharp
~ or blunt tips. The retractors are used for exposure of the frac-
~ ture by inserting the retractor around the bone taking care not
·=-e to damage periosteum or other vital structures. The sharp tip
~ helps positioning the retractor around and on the bone. Only
] light pressure should be applied to the wound edges, and there-
=
c tractor position changed frequently to prevent tissue necrosis .
..§ Since they are levers, one must remember that they multiply the
'a= force applied to them.
e
-.:..
~
=
"-
• 360
Chisel Handle
This handle, 185 mm, is used with the chisel blades described
below. The handle has a screw with a hexagonal recess with
which the blades are fixed in position using the large hexagonal
screwdriver or Allen key. The hole adjacent to the screw can be
used to insert a suitable instrument and use sideways move-
ments to loosena blade that is stuck. The metal plate at the end
of the handle receives the hammer blows.
Chisel Blades
These blades, 5, 10, 16, and 25 mm wide and approximately 80
mm long and 1 mm thick, have a sharp cutting edge. Mounted in
the handle, they are, for example, used to bevel the rim before
seating an angle blade plate, or to prepare the window for the
condylar plate. they are also invaluable for Judet decortication
in the surgery of pseudarthroses.
Bending forces should not be applied to the blades. The blades
should be discarded after use.
Gouges for Cancellous Bone Grafts

See Sect. 6.18.
Hammers
These hammers, 350, 500, and 700 g, are used with chisels,
gouges, and to insert nails, for example. The 500 g hammer is the
most commonly used; the 700 g hammer is used to drive the in-
struments for the insertion of intramedullary nails.
. - ...,..,._
- -"'
.
Bone Hooks
These hooks, 230 mm, small and medium, are used to apply
traction to reduce fractures in large bones.
Large Bone Hook

This hook, 200 mm, with T handle, is used when greater force
has to be applied for reduction, e. g. in pelvic and femoral frac-
tures.
361
•
6.17 Wiring Instruments and Implants
Cerclage wires may be applied for temporary fixation or as fig-

ure-of-eight fixation in conjunction with Kirschner wires in frac-
tures of the patella, olecranon, or of avulsion fractures of the
malleoli.
Some of these instruments and implants are contained in aster-
ilising tray or in a graphic case. See SYNTHES catalogue.
6.17.1 Instruments and Implants
Drill Bit, 2.0 mm Diameter --------~----~
This bit, 100 mm/75 mm, is used to pre-drill hard bone for inser-
tion of cerclage wires, or occasionally before inserting Kirsch-
ner wires. The triple wire guide is used as tissue protector.

This wire guide is employed as tissue protector and guide when
pre-drilling, or when inserting the Kirschner wires. The three
holes permit parallel drilling and insertion of wires.
Wire Passers, 45 mm and 70 mm Diameter

The wire passer of appropriate size is passed around the bone,
as close to its surface as possible. A cerclage wire is inserted into
the tip of the instrument, which will be passed around the bone
by withdrawing the instrument.
Wire Tightener
"' The wire tightener, with two pegs, 230 mm, is used to tighten
g.
~
cerclage wires with eye. The wire is inserted through the tip of
·a
.c:
the instrument and threaded through the peg, which is turned to
~ fix the wire. The peg is then placed in the slot, and turned to
"CC tighten the wire. Two wires of sizes 1.2 mm diameter may be
; tightened simultaneously. If two wires are tightened, one peg is
o= placed in the uppermost slot to prevent jamming.
~
....
=
=
~
....e
.s"'
• 362
Wire Tightener, "Fastight"
This wire tightener, 260 mm, may be used temporarily to tighten
and twist cerclage wires. After passing the wire around the
bone, it is crossed in an X fashion and anchored on each side.
The wire must first pass through the slot, then around the post.
By squeezing the handles the wire is both gripped and tight-
ened. To twist the wire, it must first be pulled then twisted. The
wire should be centred between jaws so that the twist is equal.
When the twist is completed, the wire is cut.
Holding Forceps for Cerclage Wires

These forceps, 170 mm, are special locking forceps, which en-
sure an absolutely secure grip on cerclage wires. The wire is
passed through the hole in the tip of the forceps, which locks the
wire when being closed. Two pairs of forceps are needed for
twisting wires.
Long Wire Holding Forceps

These forceps, 212 mm, grip both wire ends for twisting, and
areespecially useful when working in a deep wound. The handle
can be easily locked and released by virtue of its special ratchet.
Wire-Bending Pliers
These pliers, 155 mm, are multi-purpose pliers. They can be
used to grip Kirschner wires and cerclage wires with their fine,
serrated tip. Wires up to 2.0 mm diameter can be bent in the
jaws. Wires up to 1.6 mm diameter may even be cut.
-==
"'
"S.
....e
=
"CC
- =
"'
e=
-
~
...=
....=
"'
·c=
~
363
•
Flat-Nosed Parallel Pliers
These pliers, 160 mm, are useful for different purposes in wiring
techniques and for plate bending. The jaws open parallel owing
to the double lever joint.
Vice Grip, Self-Locking

This vice grip, 180 mm, opens to a maximum of 34 mm. The
screw at the end of one handle adjusts the distance between the
closed jaws; the flap on the other handle is lifted to release
the grip.
Wire Cutter, Small

This cutter, 165 mm, is used for cutting wires up to 2.0 mm.
Wire Cutter, Large

This cutter, 220 mm, has a double lever joint and can be used for
cutting wires up to 2.5 mm diameter, as well as to shorten and to
trim mini-plates.
Wire Cutter
This cutter, 230 mm, is used for cutting wires up to 1.25 mm di-
ameter. The long handles facilitate cutting wires in areas with
limited vision.
Wire Cutter
This cutter, 175 mm, is used for cutting wires up to 1.25 mm di-
ameter, has a cutting edge that allows cutting at the very tip,
which is especially useful when working with fine diameters and
small bones.
Bending Iron for Kirschner Wires

This iron is 1.6-2.5 mm in diameter. The iron is passed over the
shortened Kirschner wire end and bent over at the flat side. It
"'~ may also be used as a bolt to hammer in the bent-back wire end.
C"
·=
'5 Bending Iron for Kirschner Wires
~ ---- ~
"C This iron, 0.8- 1.25 mm diameter, is double angled and used to
;
--==
bend the smaller diameter wires close to the bone or skin sur-
.~ face.
~
e
Q,j
.s-
e
"'
• 364
Implants
The cerclage wires and Kirschner wires are manufactured of the

same stainless steel as are the screws and plate. The Kirschner
wires are available also in titanium alloy.
Cerclage Wire Coils

These coils are available 0.8, 1.0, 1.25, and 1.5 mm in diameter,
and in 10 m lengths. The desired length is cut with a wire cutter.
Cerclage Wires with Eye

These wires are available 0.8, 1.0, 1.25, and 1.5 mm diameter
and 180 mm long, and 1.0, 1.25, and 1.5 mm diameter and 600
mm long The cerclage wire with eye is used in the cerclage
wiring technique, especially when the wire tightener with pegs is
employed.
Cerclage Wires in Pre-Cut Lengths

These wires are available in the following sizes:
- 0.4 mm diameter and 150 mm long
The pre-cut length helps in identifying the diameter of the wire.
Kirschner Wires with Trocar Tip

- 0.6 and 0.8 mm diameterand 70 mm long
- 1.0, 1.25, 1.6, 2.0, 2.5, and 3.0 mm diameter and 150 mm long
- 1.6, 2.0, 2.5, 2.5, and 3.0 mm diameter and 280 mm long
These are the standard Kirschner wires used for both temporary
and definitive fixation. They may be inserted using the small air
drill with Jacobs chuck, or the mini air machine (small diameter
wires), In hard bone, however, pre-drilling the cortex with a drill
bit of similar size is recommended. -==
"'
--=
'Q.
Kirschner Wires with Threaded Tip e
- 1.6 mm diameter, 5 mm thread length, and 150 mm long
- 1.6, 2.0, 2.5 mm diameter, 15 mm thread length and 150 mm
-=e
=
=
"'
~
-
long
~
e
- 2.5 mm diameter, 15 mm thread length and 200 mm long =
The Kirschner wires with threaded tip are used when the wire ~
.5
needs secure anchoring in the cortex.
~
'"'
365
•
Kirschner Wires with Double Trocar Tip
- 0.6 mm and 0.8 mm diameter and 70 mm long
- 1.0, 1.25, 1.6, and 2.0 mm diameter and 150 mm long
The double-pointed Kirschner wires are used for retrograde in-
sertion, for example, in the hand.
Telescoping Wire Guide

This wire guide is fitted on the small air drill for insertion of a
long Kirschner wire, thereby preventing buckling of the wire.

This chuck may be used to insert the large diameter Kirschner
wires.
6.17.3 Tension Band Wiring Technique
Tension band wiring is mainly indicated in fractures of bones

serving as ligament or muscle attachments. These includes frac-
tures of the patella and the olecranon. Fractures (or osteo-
tomies) of the greater trochanter and avulsion fractures of the
malleolus may also be treated with tension band wiring.
If strong rotational forces act upon the fracture site, two parallel
Kirschner wires are inserted before the tension band wire is ap-
plied.
Principle of Tension Band Wiring

The wire absorbs the tensile forces, the bone absorbs the com-
pression forces. See also Sect. 4.1.
Tension Band Wiring of the Olecranon

- The fracture is reduced and temporarily fixed with a pointed
reduction forceps. The distal point may be introduced in a
previously drilled cortical hole (Fig.l).
- Using the triple wire guide for aiming and tissue protection, a
• 366
1.6 mm diameter Kirschner wire is inserted from proximal to
distal. In hard bone, pre-drilling with the 2.0 mm drill may be
necessary.
- The triple wire guide is placed over the inserted wire, and a
second wire is inserted through the guide, parallel to the first
(Fig.2).
- A cerclage wire, 1.0 mm or 1.2 mm in diameter, about 500
mm long, is prepared with a small twisted loop placed eccen-
trically. The shorter end is inserted through the pre-drilled
hole.
2 - The longer end is crossed over in a figure-of-eight fashion,
and passed through a curved needle under the triceps tendon,
and around the Kirschner wires (Fig. 3).
- The free ends of the cerclage wire are crossed at the same lev-
el as the prepared loop.
- Tightening of the wire loops to create symmetrical interfrag-
mentary compression is done in several stages:
- The loops are gripped with the wire bending or parallel pli-
ers and tightened by pulling perpendicular to the axis of the
bone.
- The wire ends are then twisted whilst slightly diminishing
the tension to take up the slack. This technique prevents
one end being wound around the other (Fig.4).
- The procedure is repeated, alternating from one side to the
other, until the figure-of-eight wire lies flat and taut on the
bone surface (Fig. 5).
- The Kirschner wires are slightly pulled back and cut obliquely
to create a sharp point. They are thereafter bent back through
180 o to form a small hook (Fig. 6).
- Using the bending iron for Kirschner wires, 1.25-2.5 mm, as a
punch the ends are tapped back into the bone over the wires
(Fig. 7).
5 - The tension of the wire is examined, and the twists shortened
and bent over to lie flat on the bone (Fig. 8).
- "'
c.=
~
8
....e
-==
-e=
~
"'
Q,l
-...."=...='
0!)
·c=
~
367
•
Tension Band Wiring of the Patella
- With the knee flexed to 110-120 o a straight longitudinal inci-
sion is made directly over the middle of the patella.
- The fracture is exposed and the fracture surface cleaned. Any
depression is elevated, and, if necessary, the defect filled with
cancellous bone.
~ ~r~
.'
II ·.:,_
- The proximal patellar fragment is held with a reduction for-
ceps and tilted to expose the fracture surface (Fig.1).
- With the 2.0 mm drill bit, two parallel holes are drilled in the
proximal fragment 5-6 mm from the anterior patellar sur-
2
face.
- A 1.6 mm Kirschner wire is inserted into the first hole to serve
as a guide for the second drill hole. The two holes should be
spaced 20--25 mm apart.
- A second 1.6 mm Kirschner wire is inserted into the second
hole; both are subsequently replaced with 2.0 mm drill bits
inserted in a proximo-distal direction (Fig. 2).
3
- The fracture is reduced and fixed with the double-pointed
patella forceps.
- Using the two 2.0 mm drill bits, the drill holes are completed
4
in the distal fragment (Fig. 3).
- Two 1.6 mm diameter Kirschner wires are inserted in the pre-
drilled holes; their proximal ends are bent to form a hook,
and cut obliquely to form sharp points (Fig. 4).
- A 1.2 mm diameter cerclage wire with eye is passed around
the Kirschner wires over the front of the patella, and the end
of the wire brought through the eye.
- Using the wire tightener, the cerclage wire is tightened, its
free end bent over, cut short and anchored (Fig. 5).
- The hooked ends of the Kirschner wires are hammered into
5
the bone over the wire. The protruding distal ends are
trimmed at about 10 mm from the bone, and bent back only
slightly, so that later extraction is not hampered (Fig. 6).
- A second wire, in a figure-of-eight configuration, is often
used (Fig. 7).
Variation: A cerclage wire with loops on either side may be used
and tightened as described above in olecranon fractures (Fig. 8).
• 368
6.17.4 Instruments for Tension Band Wiring
See the illustrations.
6.18 Bone Grafting Instruments
Whenever a cortical or major cancellous defect remains after

reduction of a fresh fracture , autologous cancellous bone graft-
ing is recommended. The site for harvesting should always be
prepared from the beginning to avoid redraping during surgery.
Instruments for harvesting bone grafts should always be at
hand.
6.18.1 Interchangeable Gouges, Chisels, and Impactors
Some of these instruments can be obtained in a sterilising tray or

a aluminium case.
-=
<IJ
-....==
~
6
<IJ
Oil
iS=
.
~
1-'
~
=
=
369
•
This handle connects to the gouges, chisels, impactors, and
rasps with quick coupling ends. The bolt on the handle is
pressed down, and the selected instrument inserted and turned
until locked in place.
Gouges
These gouges are straight (in 5, 10, and 15 mm widths) and
curved (in 5, 10, and 15 mm widths). The gouges are connected
to the handle with quick coupling, and, for example, used to
take strips of corticocancellous bone from the iliac fossa and the
posterior part of the ilium.
Chisels
The chisels are straight (in 4, 8, 16, and 20 mm widths) and
curved (16 mm in width). The chisels are connected to the han-
dle, and used to cut a window in the cortex to allow harvesting of
pure cancellous bone.
Cancellous Bone Impactors

The cancellous bone impactors are available in the following
sizes:
- 6 mm and 8 mm, round, curved
- 6 mm, flat, curved,
- 6 x 16 mm, 10 x 20 mm, 10 x 30 mm, rectangular.
The impactors are used to pack the cancellous bone graft into a
defect, or carefully to reconstruct an articular surface by push-
ing depressed fragments from within the bone.
"'
~
=
C"'
·=
.c
~
~
"C
=
--=
~
=
·=
~
Rasps
e
~
--==
...
"'
The rasps are round and half-round, and may be used to "file"
off sharp bony edges.
• 370
6.18.2 Donor Sites for Bone Grafts
Corticocancellous bone is best obtained from the following

sites:
- From the iliac fossa: A skin incision is made 20 mm lateral or
medial to the iliac crest. The inner table of the iliac wing is ex-
posed deep to the iliacus muscle. Long, parallel strips are tak-
en with the gouge and are usually cut into smaller pieces
about 15 mm long and 5 mm wide. Gelfoam is applied be-
tween the bone and iliacus muscle to stop bleeding. A vacuum
drain is used.
- From the posterior portion of the os ilium: The patient is in

the prone position, and the incision made just lateral to the
posterior iliac spine. After incision of the fascia and retrac-
tion of the muscle, the grafts are taken with the gouge. The
gouge with 10 mm wide blade, straight or curved is used in
most cases. For small chips, the 5 mm gouge is chosen.
Pure cancellous bone is available in abundance in the greater

trochanter and the head of tibia. If necessary, cancellous bone
can be obtained from any accessible metaphysis:
- From the greater trochanter: A lateral oval opening is cut
with the chisel, and pure cancellous bone is harvested with a
curette. The trabeculae of the femoral neck should not be
damaged.
- From the head of the tibia: A skin incision is made about 30

mm below the tibial plateau. The periosteum is longitudinally
split and retracted. An oval cortical opening is cut with the
gouge, and cancellous bone is harvested with a large curette.
Particularly in younger patients, large amounts of very high-
quality cancellous bone can be obtained in this way.
-=e
"'
--==
~
Bone grafts should be kept in a sponge moistened with Ringers
lactate solution or blood until used. Immersion in solutions "'
should be avoided. "'
=
~
if
~
"'
~
=
~
=
Q
371 •
6.18.3 Application of Cancellous Bone Graft
When filling defects resulting from compression of the metaph-

ysis or defects in the diaphysis, it is desirable to apply the cancel-
lous bone graft with light pressure. This is done most effectively
by packing the cancellous bone into the defect with the cancel-
lous bone impactors. Note that the graft incorporates by the in-
growth of fine vessels into the pores of the graft. If it is too tight-
ly impacted so as to abolish its spongy form, vascularisation may
be delayed. The opposite cortex (for buttressing) can be grafted
with pure cancellous bone (e. g. from the greater trochanter) or
with small corticocancellous chips (taken from the inner surface
of the upper ilium).
If bone infection is present, only pure cancellous grafts should
be used.
6.19 Instruments for Removal of Damaged Screws
If a screw breaks or is otherwise damaged, removal may be im-

possible. If attempts to remove the damaged screw would lead
to extensive bone damage, the screw should be left in.
Only if a free medullary cavity is required for intramedullary
nailing, or the insertion of a prosthesis, must the screw be re-
moved, also if problematical.
6.19.1 Instruments
The instruments are available as a set in a sterilising tray or in a

small aluminium case.
Conical Extraction Screws

These screws, with left-hand thread, are used to remove screws
[IJ
with a damaged hexagonal socket. Connected to the T handle,
~ the correct size conical extraction screw is screwed into the
·2' socket with left-hand turns. Three sizes are available: one for
'5 the 1.5 mm and 2.0 mm screws, one for 2.7, 3.5 mm and 4.0 mm
~ screws, and a third for the 4.5 mm and 6.5 mm screws.
-=
=
0=
~
~
....
e=
~
......=
.s
[IJ
• 372
Hollow Reamers
The hollow reamer is an assembly of a shaft with a quick cou-
pling end, a reamer tube, and a centring pin. Six different ream-
ers are available: one each for screw sizes 1.5 mm, 2.0 mm, 2.7
mm, 3.5 and 4.0 mm, 4.5 mm, and 6.5 mm.
The method of assembly for the three larger sizes, 3.5 mm, 4.5
mm, and 6.5 mm and the three smaller sizes 1.5 mm, 2.0 mm and
2. 7 mm are shown in the two sets of figures.
The reamers cut anticlockwise, and are used to ream to and
around a screw fragment. It is connected to the T handle and
z:c-;zwwa- cr turned anticlockwise
The small air drill may be used with the reverse trigger; but only
with extreme care only since the reamer is easily damaged.
Extraction Bolts
These bolts have an internal conical left hand thread with which
to engage and extract the exposed screw fragment. They are
connected to the T handle and turned anticlockwise while pres-
sure is exerted on the screw fragment.
Six different sizes are available: one each for screw sizes 1.5
mm, 2.0 mm, 2.7 mm, 3.5 and 4.0 mm, 4.5 mm, and 6.5 mm.
T Handle
The T handle, with quick coupling, is used to turn the extraction
bolts and the hollow reamers.
Sharp Hook
This hook is useful in removing debris from the screw head or
around the screw fragment.
Hollow Gouge
This gouge is used to expose the end of the screw fragment so
that the hollow reamer can be centred over the remnant. The
500 g hammer is required.
373
•
Forceps for Screw Removal
These forceps is used to grasp and extract exposed screw frag-
ments. The closure can easily be operated with one hand. It may
be firmly locked on the screw fragment and turned for removal.
Spare Centring Pins for Hollow Reamer

These pins, available in six different sizes, are replacements for
---
T ER?TF....
the centring pins assembled with the six sizes of hollow reamers. ·.
They are assembled in the proper size hollow reamer shaft by
turning anticlockwise.
Spare Reamer Tubes for Hollow Reamer

i f ."5·&
These tubes, available in six different sizes, are replacements for
} j'Jik'" 'S £ffj.5
the reamer tubes of the complete hollow reamers. They are as-
sembled by turning them clockwise.
Application Diagram
This diagram, with schematic illustration of application, may be
used as a guide during the a procedure. It is made of anodised
aluminium and can be sterilised together with the instruments.
Entfernen von abgebrochenen Schrauben

Removal of broken screws
Extraction de vis cassees
Rimozione delle viti spezzate ,_:>o"'f ... ~-··- ........- -
~·-=::.:.'-;;.~:..- -~ ... - ~.:~.:
..
ol>fol.
==~.:.~'"':'.::... .:::;~~- =:::::::;

1.1 §:f:::::::~:::.::::::
'\J . . . . . . __ .......,_,._...04.......
~=--=:.-:!...--=:~ ~
~:==---=::..~===: L(~"~~:r;.;:-,~,..--,,.,-...,.,.,-
:;,~..::.:~:;:~~~...';:= .. , ....
=~··-
...,... . . - . . . . . . . .-.. .
..........._._..._
::-='=::.::.....o:~~=
... .............-...
..u-~ ...... ~.-•-
(.
~·-u-
..
:;:,..~--tona.-..w. -•,..,..~ -
.
-.
---- -
....,........__ ,.,......,.,__
...... .,.-
m.-.o _ _ _ _ .,.., .... •
.......... .
. . ..J--. ................. , ...... .
I
....
··-4
__ ..._.._
....,..... _ _ .. _ .... &..-_
_ _ _ ,_,,._ _ _ .......Ofil' •
..... :..:_.........
..~·.·........
[_·~•c
.....
"-•r~~--d
__.,..
.=-=-. . .: :;. : .;: .-:--..:.·.: .........
..: -
·~;::::...::';...::-:.=:-
-~
''"'..
:Kifn
-------
...... ... --~·~··· .
-·--··· ...
,....
..
-~·---
. " - ·--·~·
im
• 374
Additionally Necessary Instruments
A hammer, 500 g, is necessary for the use of the hollow gouge.
Countersinks, 2.7-4.0 mm, and 4.5 mm, may be used to ream
the cortex to expose the screw fragment.

This bit, of chrome-plated high-speed steel, was used to drill
away the damaged large screw head. Its use is, however, not rec-
ommended since it creates heat and metal debris. The extrac-
tion bolts are used in its place.
6.19.3 Application Technique
See also the application diagram.

Removal of deep-seated screw fragments:
- A recess is produced in the cortex with the countersink of ap-
propriate size, or with the hollow gouge.
- The hollow reamer of correct size, coupled to the T handle or

small air drill, is turned anticlockwise until the centring pin
reaches the screw fragment. The centring pin is then removed
by clockwise turns.
- The hollow reamer is turned around the screw fragment until
approximately 5 mm length is exposed.
- The extraction bolt of correct size is coupled to the T handle.

While applying pressure, the extraction bolt is screwed in an
anticlockwise direction onto the screw fragment.
375 •
- By continuing turning the extraction bolt, the screw fragment
is unscrewed and removed.
Removal of a screw with damaged hexagonal socket:

- The correct size conical extraction screw is selected, connect-
ed to the T handle and placed vertically in the damaged screw
head. By applying pressure and turning anticlockwise the
screw is removed.
6.20 Aiming Device
The aiming device has various interchangeable attachments for

different applications (see below).It can be obtained as a set in
an insert tray for aluminium cases.
Measuring Bar
This bar is assembled with the locking sleeve, and one of the
hooks. The scale allows measurements up to 180 mm.
"'<II Locking Sleeve

=
·[ This sleeve is slid onto the measuring bar in the direction of the
'5 arrow on top, and fixed in the desired place with the screw. The
~ sleeve has an inner diameter of 6.0 mm, and accepts the differ-
"CC
; ent drill sleeves with screw connection.
=
--==
.~
<II
=
-=
...
.5"'
• 376
Small Hook and Large Hook for Knee
The large hook may be used for repair of the cruciate ligament.
The small hook is applied for measuring. The distance between
the inserted drill sleeve and the tip of the hook is read from the
scale on the bar.
Hook for External Fixator

This hook is employed for the application of a bilateral external
fixator. See alsop. 327.
{(
il,j
~
·;:
il,j
·s=
~
<
377
•
Offset Pointed Hook
This hook can be used as aiming device on the proximal femur.
When the offset pointed hook is used, 40 mm must be added to
the measurement read from the scale to compensate for the off-
set. Thus the distance y =x + 40 mm.
10mm
04,5 :
Forked Impactor
This impactor is used to position the offset pointed hook in the
bone by tapping lightly with a hammer.
Check Tube
"'~ This tube is used to check the correct axis between the locking
·2' sleeve, and the hook for external fixation.
'5
~
"C
=
~
.::=
--==
--
a
~
:I
~ ;- I
"""
• 378
This trocar is used with the drill sleeve, 3.5 mm, which is screwed
in the locking sleeve.
Drill Sleeve, 3.5 mm, 110 mm

This drill sleeve is screwed in the locking sleeve, and used with
the drill bit, 3.5 mm, when the aiming device is employed for ap-
plication of a bilateral external fixator frame. The trocar 3.5 mm
is inserted and the assembly pushed through a stab incision onto
the bone.
Drill Sleeves, 2.0, 3.2, and 4.5 mm

These drill sleeves are screwed in the locking sleeve and used
with the corresponding size drill bits.
Drill Sleeve, 2.0 mm, with Two Parallel Holes

This sleeve is used to drill two parallel holes for insertion of su-
tures in cruciate ligament repairs.
Drill Bits
Drill bits 6.0, 4.5, 3.5, and 3.2 mm, 195 mm/170 mm, and drill bit,
2.0 mm, 125 mm/100 mm, are used for different applications in
conjunction with the aiming device.
Drill Bit, 6.0 mm, Three-Fluted

This bit, 5 mm/170 mm, may be used to prevent slipping off an
oblique bone surface, for example in cruciate ligament repairs.
Suture Passer, 2.0 mm Diameter

This passer, for quick coupling, is used to drill two parallel holes
for the sutures in cruciate ligament procedures.
- -- 1) Suture Pusher
This passer is used to push the suture through a pre-drilled hole
in cruciate ligament repairs.
~
~
·;:
~
Q
·e=
~
<
379
•
6.21 Compressed Air Machines
6.21.1 Compressed Air as Power Source
The reason for choosing compressed air as power source for the
AO/ASIF power equipment, was based on the following con-
siderations:
- Easy availability of compressed air throughout the world
- Safe handling of compressed air
- Safe and easy sterilisation of air machines
- Variable and easy speed control
- Rapid stopping because of the machine's low inertia
- Relative light weight of air machines.
Compressed air as a power source has proved reliable and effec-
tive for more than three decades. It may be supplied either from
a central supply system through pipes into the operating room,
or from separate cylinders. Compressed nitrogen is a possible
substitute.
Never Use Oxygen: There is a danger of fire and explosion!
6.21.1.1 Compressed Air (Nitrogen) from Cylinders

in the Operating Room
Compressed air cylinders are available in various sizes, with fill-

ing pressures 150-200 bar (2200- 3000 psi). The most commonly
used size has a capacity of approximately 6m3 (6000 1). The
quantity of air remaining in the cylinder can be estimated from
the pressure gauge. At 200 bar (3000 psi) the cylinder is full; at
100 bar (1500 psi) it is approximately half-full.
The air pressure (gauge A , also indicating the content) must be
checked before each use, to ensure that enough air is available
for the procedure. Approximately 3 m3 (3000 1) are needed for
screw and plate fixation, about 5- 6m3 (6000 1) for reaming of a
medullary cavity. It is recommendable to have extra cylinders
available, preferably with a reduction valve mounted and ready A B
"' for replacement. The operating pressure for the machines (6
~ bar or 90 psi) is set on the pressure-regulating valve (gauge B),
·a=- while the machine is running.
"5 Pressure indicating and regulating valves may differ from coun-
~
~ try to country; the principle of function, however, remains the
§ same. Compressed air, or nitrogen, from cylinders is generally
.§ clean, dry, and ready to use, but to ensure optimal function it is
-e=
";
~
recommended always to use a filter system (see below).
-==
...
...."'
• 380
6.21.1.2 Compressed Air from a Central Supply System
In large hospitals air compressors, or a battery of air cylinders,

are installed usually in the basement for the supply of com-
pressed air. Through pipe lines the compressed air is carried to
the operating theatre, where it is reduced to the required pres-
sure and piped to wall outlets in the different rooms.
The pressure of the central supply system is normally adjusted
to 10-12 bar (145-180 psi), which can be verified with an on-line
pressure gauge. The critical pressure for triggering restarting of
the compressor should not be below 8 bar (120 psi). The air
reservoir and pipe lines to the operating theatre should be as
large as possible to ensure that the pressure does not fall below
the minimum required.
The necessary quantity of air is about 250-350 1/min per ma-
chine. The corresponding power requirement of the compres-
sor motor is approximately 1.3-1.8 kW, depending on the dis-
tance to the operating room. The compressor should always be
at lowest point of the compressed air circuit. Separators are nec-
essary in the system to filter small particles of oil, dirt, and water
that may be contained in the system.
The purity of the compressed air from a central supply system
can only be ensured by continuous testing of the air at the wall
outlet, or by installing a filter. Only then may the compressed air
entering the machines be free of particles and microorganism.
6.21.1.3 Filters for Compressed Air

c
The filters described below are available for use in countries
where special filter system do not already exist. The SYNTHES
distributor can give further information about these installa-
tions.
Coarse Filter (A)

It is normal that rust, water, and condensation form in the pipe
lines of a central supply system for compressed air. To retain
this debris and condensation it is recommended that a coarse
filter be installed. This should be upstream of the pressure regu-
lating valve and connection point in the operating theatre. The
risk of damaging the valves and the air machines is thereby re-
duced.
M icrofilter (B)
This shock-resistant mechanical filter, is installed downstream
of the pressure regulating valve (in the 6 bar or 90 psi area) to
render the air free of particles as minute as 111m diameter. The
protective glass of the microfilter has to be removed and
cleaned every 2 weeks after shutting down the air supply. See
381 •
Sect. 6.22.9.10. The filter cartridge has to be changed whenever
there is noticeable speed reduction of the air machine, or at least
every year.
Fine Pressure Regulator (C)

If a tourniquet is connected (a), a fine pressure regulator has to
be used downstream of the 6 bar/90 psi regulating valve. The air
machine is connected at branch (b). This fine pressure regulator
further reduces the air pressure and can be set to the desired lev-
el with the knob (c). See Fig. on previous page.
6.21.2 Air Hoses and Exhaust Diffusor
Compressed air is supplied to the air machines through air hoses

with special couplings to fit both the machines and the outlets
from the air supply. The latter differs from country to country
and the corresponding couplings of the air hose may have to be
adapted.
Double Hose System

The double hose system was developed to prevent air exhaust
and turbulence near the operating field. An inner hose supplies
the compressed air to the machine, and the outer hose serves as
the exhaust away from the machine. The double-hose coupling
is designed so that it connects to both the air inlet and the air
outlet nipples.
In an emergency the double-hose couplings may be connected
to machines with single-hose couplings. However, the advan-
tage of the remote exhaust system, is then no longer func-
tional.
By the use of the double hose system it is also possible to con-
duct air exhaust away from the operating theatre. Special dou-
ble hose wall couplings are available for this purpose. See SYN-
THES catalogue.
To prevent loss of power the total length of the hose should not
exceedS m.
~ Shorter lengths of hoses are easier to handle than one long hose.
S. Double air hoses are available in lengths of2,3, 4, and5 m. A dou-
·a ble spiral air hose is available with a working length up to 2 m.
'5
~
'1:l Single Hose System
=
<:':1
= The single air hoses were previously used with the single-hose
-=e
.5!
....
~
machines. The disadvantage was that the air exhaust was near
~
the operating field, causing turbulence and possible contamina-
tion.
.......
~
A single-hose is sometimes used unsterile as the extension be-
.5 tween the wall coupling and the sterilised hose connected to the
• 382
machine. The exhaust air then exits at the couplings and may
cause turbulence unless an exhaust diffusor is used.
Two types of single air hoses are available: One is a lightweight
spiral air hose of thermosetting plastic with a working length of
2m. The other is a regular single hose, which is mostly used as an
unsterile extension hose in conjunction with the diffusor and the
double air hose. It is available in lengths of2 or 5 m.
Exhaust Diffusor
The exhaust diffusor has a filter which releases the exhaust air
with minimal turbulence. It may be useful in operating theatres,
where the exhaust air cannot be channelled to an exhaust sys-
tem outside the operating theatre.
The diffusor is connected to the sterile double air hose at one
end, and to a single hose at the other end. Inside the diffusor is
an interchangeable microfilter cartridge. This filter must not be
sterilised, and is replaced only if damaged, or if there is a drop of
operating pressure (clogged pores of the filter). The cartridge is
changed by loosening the three hexagonal screws with the large
screwdriver, and dismantling the casing. The cartridge is re-
placed, and the two casing parts compressed to retighten the
three screws. See also Sect. 6.22.9.10
6.21.3 Air Machines and Accessories
Before use, the compressed air machines should always be test-

run. It is recommended that a filter system be used with all air
machines and the oscillating saw to ensure optimal function (see
above). See also SYNTHES catalogue for further details. For
care and maintenance see Sect. 6.22.9.
6.21.3.1 Small Air Drill and Accessories
Small Air Drill
The small air drill is designed for single-hand use, and has a for-
ward and a reverse trigger. The small air drill can be used for
drilling, tapping, and insertion and removal of screws and
Kirschner wires.lt cannot be used for medullary reaming.
The quick coupling of the small air drill allows easy and safe
connection of instruments with a quick coupling end. Sterilisa-
tion, or long periods of disuse may cause the motor to stick. The
machine should always be test-run before an operation. A stuck
motor may be released by turning the quick coupling.
383
•
The small air drill is equipped with a double hose coupling
(left).When used with a double hose the air exhaust away from
the operating field. Old-style machines with single air hose cou-
plings may still be in use (right). It must be noted that the air ex-
haust then causes turbulence near the operating field increasing
the risk of cross-contamination. For care and maintenance
seep. 424, 426.
Technical Data
- Variable speed: 0-800 rpm (10%)
-Torque: 2.4 Nm (22 in./lb,
approximately)
- Regulator pressure
with running machine: 6 bar (90 psi)
- Compressed air
consumption approximately: 250 llmin (9 cu.ft./min)
- Weight: 630 g (approximately 22 oz)
Quick Coupling of Instruments

''
Instruments with a quick-coupling end can be attached by push-
ing the coupling sleeve forward, inserting and turning the in-
strument until it clicks into place. The instrument is locked in
place when the coupling is released. Detachment is possible by
pushing the quick coupling forward.
Instruments that can be coupled are:
- Drill bits
- Taps (Caution)
- Screwdriver shafts
- Router
- Accessory instruments (see below)
Operation
~ The lower trigger is depressed with the middle finger for for-
=
Q"' ward motion, and regulates the speed up to approximately 800
·=
.=
C.l
rpm. By depressing both triggers simultaneously, the direction
~ of motion can be immediately changed to reverse even when the
2l drill is running.
--e=
~
.s= Applications
~
~ Drilling and reaming for DHS/DCS is done by forward motion

only, even when retrieving the drill. Bone debris may otherwise
E
"';; block the drill. It is recommended that the wound be irrigated
....=
• 384
with Ringer's lactate solution during drilling. Heat necrosis, and
bacterial contamination of dry tissue can thereby be avoided.
In special situations it may be possible to tap with power. How-
ever, it is regarded as extremely dangerous and must be per-
formed with greatest care. The machine must "follow" the tap,
and no pressure be exerted. As soon as the tap protrudes from
the opposite cortex it must be immediately reversed. If this is
not done, great damage to viable soft tissue may be the result.
When reversing the tap, it must not be pulled. The pre-cut
thread in the bone may otherwise be damaged.
Insertion of screws may be performed with the screwdriver
shafts. The screw must engage the pre-cut thread properly be-
fore running the machine, to avoid jamming. The screw is finally
tightened by hand.
Removal of screws with the screwdriver shaft is possible; after
cleaning the hexagonal socket, and loosening the screw manual-
ly, the machine is run in reverse.
Accessories
Jacobs Chuck with Key

This chuck is connected to the small air drill for insertion of
Kirschner wires, and for use of instruments with round and tri-
angular ends up to 4.0 mm and 4.5 mm respectively. The key is
used to tighten and open the chuck.
Quick Coupling for Small Air Drill

This is used to connect the DHS/DCS reamers, as well as large
drill bits used for cruciate ligament repair. The outer sleeve is
pushed forward to insert and couple the instrument.
Mini Quick Coupling Chuck

This chuck connects drill bits and reamers that have mini quick
coupling end. The outer sleeve is pushed back to couple the in-
struments.
385
•
Oscillating Attachment
This attachment converts the rotating motion of the small air
drill to a back-and-forth motion over an arc of about 270°. The
oscillating motion reduces the risk of damage to blood vessels
and nerves by preventing spooling of soft tissue around the drill
bit. The oscillating attachment is locked in place around the up-
per trigger of the small air drill. By pushing the outer sleeve of
the attachment forward the drill bit is inserted and turned until
it "clicks" into place. Releasing the sleeve locks the drill bit.
The attachment is used preferably with a three-fluted drill bit,
which prevents slipping on an oblique bone surface.
Radiolucent Drive
This drive is connected to the small air drill and allows accurate
drilling of for example locking holes of medullary nails under
image intensification. It is slid onto quick coupling of the small
air drill, and the two parts pressed together until they engage.
Additional locking is not necessary. The drill can be rotated
around its own axis to the desired working position. While run-
ning the machine with one hand, the radiolucent drive is held
with the other hand. The length of the drive places the surgeons
hands at the periphery of the radiation zone (seep. 283 ). Thera-
diolucent drive is used with three-fluted drill bits that have a
special coupling end. The quick coupling of the drive is pushed
forward and the drill bit inserted and turned to be properly seat-
ed. It is locked in this position by pulling back the quick cou-
pling.
Three-fluted drill bits for radiolucent drive are available in
SIZes:
- 4.0 mm diameter, 150 mm/120 mm (total length/effective
length) used for the 3.9 mm locking bolts for unreamed tibial
nails.
- 3.2 mm diameter, 150 mm/120 mm (total length/effective
length), used for the 4.9 mm locking bolts for universal
"'~
=
="
femoral and tibial nails.
'2 Further diameter drill bits for other applications are also avail-
'S able. See SYNTHE S catalogue. Seep. 427 for care and mainte-
~ nance.
-==
~
=
--=
Telescoping Wire Guide
.~
~
This guide may be fitted on the small air drill when inserting
e long Kirschner wires. It helps to avoid bending of the wire.
~
-
-
:I
...
~
• 386
6.21.3.2 Universal Air Drill and Accessories
The Universal Drill
The universal air drill is a more powerful drill, used with the
right-angle drive especially for medullary reaming. Different at-
tachments allow the use of the universal air drill also for other
applications, such as drilling, insertion of screws and Kirschner
wires. The drill is designed for single-hand use, and for forward
motion only.
Note: The universal air drill should not be connected directly
with the flexible shafts, since the machine is not cannulated to
accept the reaming rod. Acetabular reamers with correct cou-
pling end for hip replacement can, however, be inserted directly.
For care and maintenance seep. 424,427.
Technical Data
Two-stage speed:
First stage 200rpm
Second stage 450rpm
with running machine: 6 bar (90 psi)
- Compressed air
consumption approximately: 300 1/min (9 cu.ft./min)
-Weight: 800 g (approximately 28 oz)
Accessories
The following accessories can be attached to the universal air

drill:
Small Quick Coupling

This allows use of all instruments which have a quick coupling
end such as drill bits, taps, screwdriver shafts, router. By pushing
the small quick coupling into the universal air drill's coupling, it
is locked in position. It is disconnected by pulling back the outer
sleeve of the coupling of the universal drill.
Quick Coupling
This is used to connect the DHS/DCS reamers, and the large drill
bits used for cruciate ligament repair. The outer sleeve of the
large quick coupling is pushed forward to insert and couple the
instrument, the assembly then pushed into the universal drill.
387
•
Jacobs Chuck with Key
This chuck is connected to the universal air drill for the insertion
of Kirschner wires, and for the use of instruments with round
and triangular ends up to 6.0 mm and 6.5 mm, respectively. The
key is used to tighten and open the chuck.
Universal Chuck
This chuck is a larger chuck for insertion of Kirschner wires, and
for use of instruments with round and triangular ends up to 6.0
mm and 6.5 mm, respectively. It is tightened and opened by
turning the chuck.
Right-Angle Drive
This has to be used when reaming the medullary canal with the
flexible shafts and reamers. It is cannulated to accept the ream-
ing rod. The right-angle drive of recent design is tightened in the
desired position on the machine with the locking screw (usually
at 90 °). The flexible shaft is inserted by pushing the end into the
coupling of the right -angle drive. By pulling back the outer quick
coupling sleeve of the drive the instrument is disconnected.
6.21.3.3 Oscillating Bone Saw and Accessories
The Oscillating Bone Saw
The oscillating saw is especially useful for osteotomies. The saw

blade can be positioned in line with the handle of the machine,
"'
~
like an osteotome, but may also be fixed at 45 o and 90 o angles.
§. A key is used remove the locking screw and to fix the saw blades
·a in position. For care and maintenance seep. 424, 428.
'5
~
-= Technical Data
=
=
=
0
- Oscillation frequency: up to 18 000 per minute
~ - Regulator pressure
.....
= with running machine: 6 bar (90 psi)
e
~
- Compressed air consumption: 1451/min (approximately
........= 5.5 cu.ft./min)
"'
....= - Weight: 575 g (approximately 20 oz)
• 388
Operation
The cutting speed may be regulated continuously by pressure
applied to the side lever. When not in use, the lever should be
locked to prevent inadvertent activation of the saw. The saw
should always be running before making contact with the bone.
Heavy pressure must not be applied as this may jam the teeth of
the saw blades in the bone. Efficient cutting is achieved by mov-
ing the machine to-and-fro on the level of the saw blade allow-
ing the machine to swing slightly out of the bone on either side.
Smooth operation without force results in very precise cuts.
Jamming and inaccurate cuts are normally the result of worn
blades or too much pressure. Cutting straight into the bone
without moving the machine to-and-fro is inadvisable, as is cut-
ting into an instrument or implant.
Accessories
Saw Blades
Five interchangeable saw blades are available. They are manu-
factured from special spring steel which is responsible for their
hardness and wear resistance resulting in a high cutting capacity.
The three shorter blades have a thickness of 0.4 mm, the two
longer 0.6 mm.
Note: The longer the blade, the greater the amplitude of motion
at the toothed end as the angle of the oscillation cannot be al-
tered. The saw blades cannot be resharpened, since they would
-~-------~~ loose their set, and not function correctly. Saw blades must be
checked after each use, and worn blades replaced by new ones.
389 •
Mounting saw blades:
- The screw is loosened with the key, and removed.
- The selected blade is placed at the desired angle.
- The screw is replaced and tightened firmly.
6.21.3.4 Mini Compressed Air Machine and Accessories
Mini Compressed Air Machine
The mini compressed air machine is intended for hand, foot and
maxillofacial surgery, and is available with a variety of attach-
ments for drilling, sawing, and the insertion of fine Kirschner
wires. It is designed for clockwise motion only. The machine
should be used with the double air hose. For care and mainte-
nance seep. 429.
The mini compressed air machine and some accessories can be
obtained as a set in a aluminium case.
See SYNTHES catalogue for details.
Compressed Air Motor

Technical data:
with running machine: 5-6 bar (80-90 psi)
- Compressed air
consumption approximately: 150 1/min
"'
~ - Weight approximately: 130 g(S oz)
·a.c=-= The compressed air motor is lightweight and has a quick cou-
~ piing for the different attachments. To connect these the small
~
"= slide is pushed forward. The speed is continually variable and
; controlled by the large slide.
§ For optimal function a micro filter is recommended (seep. 381 ).
";
....c For care and maintenance seep. 429 .
e
~
-
....2
•
"'c
390
Hose Connector, 60°
This connector is attached to the end of the motor and used to
place the hose at an angle for easier operation.
Accessories
Straight Drill Head Attachment

This attachment has a speed reduction gear, which ensures a
maximum speed of 3000 rpm. It is used to connect drill bits,
burrs, and circular saws with mini quick coupling ends. By
pulling back the small coupling at the very front the instruments
are inserted and turned to be locked in place.
Drill Head Attachment 90 °

This attachment has a speed reducing gear for a maximum of
7500 rpm. The instruments with mini quick coupling are placed
at a 90 o angle in this drill head.
Kirschner Wire Attachment, 45 o

This attachment is cannulated to accept Kirschner wires of
0.6-2.0 mm diameter. They can be inserted by pressing the small
lever. To lock the Kirschner wire in place the lever is released.
The speed reduction gear allows a maximum of 4800 rpm.
Mini Oscillating Saw

This saw connects three different sizes saw blades. The speed is
reduced to 6000 oscillations/minute by the speed reduction gear.
Saw Blades for Mini Oscillating Saw

These blades, with 6 mm and 8 mm widths, and 13 mm usable
length, and 8 mm width and 18 mm usable length, are available
for osteotomies in diminutive bones. The blade is attached by
slipping it over the knob, parallel to the machine axis. The blade
is then turned through 90 ° and pushed into the slot of the head
until it clicks in position.
391
•
The blades are removed by reversing this technique. The teeth
of the blades cannot be resharpened. Worn blades are discard-
ed.
Mini Reciprocating Saw

This saw has a speed reduction gear that allows a maximum
speed of 6000 rpm.
Saw Blade for Reciprocating Saw

This blade is 45 mm long. It is inserted into the slot at right an-
gles to the machine axis. After rotating the blade about the car-
rier pin, it can be locked into place with the retaining ring. The
reverse procedure is used for removal.
Drill Bits
These bits. in sizes 1.1, 1.5, 2.0, and 2.7 mm, in lengths from 28
mm to 67 mm, and with mini quick coupling end, are available
for use with the mini compressed air machine. They may be used
with a depth stop, or with a skull guard (for trephination). The
small screwdriver is used for tightening.
A Lindemann reamer with spring guard is also available.
Burrs
;i -
Burrs, with mini quick coupling end, round, oval, egg-shaped,
straight-edged, conical, and pear-shaped, are available with dif-
ferent diameters. Burrs up to 6.0 mm diameter may be used with
a tissue protector.
Circular Saws
These saws, with 8, 10, 12, and 15 mm diameter, and 28 mm
length can be used with the mini compressed air machine. A tis-
sue protector is also available, which is fixed on the straight drill
head attachment using the small screwdriver. See SYNTHES
catalogue for details.
Double Air Hose

This is a flexible, 2m long hose, which connects to the com-
pressed air motor by a swivel coupling. The outer hose exhausts
the air away from the operating area, and can be connected
either to the diffuser, or to a exhaust air system .
• 392
6.21.3.5 Hand Drill and Accessories
The hand drill is used as a reserve in emergency situations, for

example if the compressed air machine, or air supply, fails dur-
ing surgery. It can also serve in situations where compressed air
and air machines are unavailable.
The drill has two speed settings. Pulling the lever near the han-
dle engages the lower gear. If the lever is pushed forward, the
drill is switched to a higher gear. The front lever is used to lock
the low gear. The higher gear is used for drilling and inserting
Kirschner wires. The lower gear is used for tapping, inserting
and extracting screws. In emergency situations, the lower gear
can be used for reaming the medullary canal.
The crank can be mounted into two positions with varying
length. The long lever arm is used to obtain greater force , the
short lever arm for greater speed.
By unscrewing the nut, the machine is easily dismantled into
four parts for cleaning and lubrication.
The machine is sterilised as general instruments (seep. 417).
Accessories
Quick Coupling for Hand Drill

This is used to connect drill bits with quick coupling end.
Universal Chuck for Hand Drill

This chuck has an opening capacity of 1.0-6.0 mm diameter, and
is cannulated to be used with Kirschner wires. It has an automat-
ic locking mechanism.
Connector for Hand Drill

This connector has a quick coupling for flexible shafts. It is suit-
able only for reamers with a maximum diameter of 12.0 mm. It
is cannulated to accept the reaming rod.
"'
:a=
~
~
~
~
...
~
"C
~
"'
..."'
~
e0=-
u
393
•
6.22 Care and Maintenance
of AO/ASIF Instrumentation
By A. Murphy
6.22.1 Definition
To define care and maintenance: it means to "look after" and
"preserve".
Surgical instruments are a very large investment for any institu-
tion. Care and maintenance of these instruments is vital to en-
sure that they remain functional. AO/ASIF instruments and im-
plants are made with great precision, and with vigilant upkeep
they should endure use for many years.
Note: The following guidelines have been recommended by the
AO/ASIF group. These may have to be adapted to suit regula-
tions and practices in different countries or environments. The
general principles for care of all surgical instruments also apply.
Since most of the instruments are made from "stainless" steel
how do they become stained, rusted or corroded? The following
chapter outlines some of the reasons and describes measures
taken to avoid such problems.
6.22.2 Causes of Corrosion
Corrosion is a gradual destruction, or wearing away, that may be

caused by a chemical action. It can occur in poorly maintained
instruments. To understand how to prevent instruments from
becoming permanently damaged, it is essential to be aware of
the sources of corrosion.
Damaged passive layer:
- If instruments or implants become scratched or dented this
can damage the passivation or protective layer on the surface.
"'~ Subsequent corrosion may develop.
CT'
] Continuous exposure to surgical exudates:
~ - Blood, pus or other bodily secretions left on instruments for
'= prolonged periods may also damage the surface.
,;
= Excessive exposure to certain solutions:
'S -
0
Saline or solutions containing iodine or chloride can react
C with specific instruments. Also harmful would be, as well as
e
QJ
certain disinfectants, if improperly used, strong acid or
S alkaline solutions. The water quality used for washing and
.Ei"' rinsing instruments may be another influencing factor.
• 394
Rust transfer:
- Poorly maintained instruments may develop areas of rust.
This can spread onto other instruments with which they come
into contact.
Stress, strain and wear:
- Instruments used incorrectly, or for purposes for which they
were not designed, will succumb to this abuse.
- If they are in constant use, natural wear is inevitable and the
life cycle will be shortened (see also Sect. 6.1.2).
6.22.3 Care in Preparation For and During Surgery
The main objective is prevention of corrosion and permanent

damage. The following procedures should be initiated to ensure
maximum care of the instruments.
- Correctly stored, appropriate sterile instruments should be
assembled for the operation. The surgery will determine what
is required. The size of instruments should correspond to the
size of the bone!
- The intact outer covering and expiry date on the pack should
be noted.
--=e
=
·=
~
-
~
2
.....s
A steriliser indicator inside the pack will confirm that the con- "'
tents have been sterilised. 0
~
~
=
-=
=
~
·;
~
"C
..u=
~
~
~
395 •
- Instruments should be arranged in sequential order on the in-
strument table. Only relevant instruments should be set out
and the remaining ones placed in a convenient position until
required.
- The sterile instruments should be prepared just prior to the
procedure. Covering the instrument table and leaving it unat-
tended is not an acceptable practice.
- Blood or other exudates should be wiped from instruments

throughout the procedure. Ringer lactate solution or saline
may be used, but the instruments should not be left to soak in
these solutions.
- Once used each instrument should be returned to its allotted
place on the instrument table.
- Each instrument is designed for a specific purpose and should
be used only for that purpose. The user should be acquainted
with its correct use and function.
- To prevent damage during use it is important that instru-

ments with multiple parts are assembled correctly. The as-
sembly is verified before use on the patient.
- Cannulated instruments are flushed to prevent bone debris

and blood drying and adhering to the inside .
• 396
6.22.4 Management Following Surgery
Once surgery has been completed, the cleaning process must

begin. Instruments should be cleaned as soon as possible. This
consists of a number of stages, each one of equal importance.
Any instruments used during surgery are regarded as "contami-
nated". Those that have been used on a patient suspected of, or
known to have, a transmissible infection may be processed in a
similar manner.
At the end of the procedure, excess blood or debris should be
wiped off to prevent it drying onto the surface.
A designated place away from the "clean area" of the operating
suite is necessary for cleaning instruments. If they are going di-
rectly to a centralised area they must be covered to avoid con-
tamination of personnel or surroundings en route.
Protective clothing should be worn when handling the contami-
nated instruments.
6.22.4.1 Dismantling
The following guidelines should be followed in disassembling

instruments:
- Instruments that have removable parts should be disassem-
bled. Any small pieces, e. g. screws, nuts or bolts, must be
carefully gathered to prevent loss during cleaning.
- It is important to note that whoever takes an instrument apart
should know how to reassemble it correctly!
- If blood or bone debris is not removed from all areas, it is
"baked" onto the instrument during sterilisation and can
cause irreparable damage.
--=
.:==
~
s
~
2
-;:
6.22.4.2 Disinfecting
.......=
Q
This is a process necessary for the destruction of micro-organ- ~
=
-=
isms and is required following any surgical procedure. At pre- ~
sent, with the ever-increasing risks to health care workers and =

~
patients, adequate decontamination of instruments is of even ·;

greater importance. This may be chemical or thermal: ~
"CS
=
..
~
~
u
~
397 •
Chemical: This involves soaking the open disassembled instru-
ments in a disinfecting solution for the recommended
time. Whatever solution is chosen it must be diluted
and used according to the manufacturers' recom-
mendations.
Thermal: Most instrument washing machines include a dis-

infecting phase. This is the preferred and safest
method of decontamination.
Note: Anodised aluminium, e. g. some instrument cases, tem-

plates, a few specific measuring devices and lengthening appa-
ratus, should not come in contact with certain cleaning or disin-
fecting solutions. Therefore it is important to check the
composition of the solution before subjecting the metal to a pos-
sible chemical reaction (see Sect. 6.1.2.2).
6.22.4.3 Cleaning
Two methods are available: mechanical or manual. Whatever

detergent is used, in either method, it should be selected care-
fully. Instructions for use and dilution must be followed. Ideally
the pH of the solution should be between 7.0 and 8.5 (see note in
"' Sect. 6.22.4.2).
=
~
·a
1;;1'
.c
u Mechanical Cleaning
~
"C
= This is the selected method available in many institutions. Sev-
~
=
-=e=
0 eral different washers/cleaners exist. Manufacturers instruc-
·-= tions should always be adhered to.
~
...=
....
-
It!
• 398
Some general guidelines:
- Firstly prepare and arrange the instruments by disassembling
multi-component instruments and opening those with ratch-
ets, box locks or hinges.
- Any sharp instruments should be removed for manual clean-

ing or put in a separate tray.
- D elicate instruments should not be washed in a machine.
- Baskets must not be overloaded and heavy instruments

should be placed on the bottom of the tray.
- Heavily soiled or cannulated instruments may need to be
soaked or rinsed prior to machine washing to loosen any
dried exudates.
--
Ultrasonic Cleaning
.::=
~
This is an alternative type of mechanical cleaning.
=
- Instruments must first be decontaminated. e
~
- Once excess or dried exudates have been removed, the in-

struments can be placed in the machine. -.-...=e"'
- The ultrasonic waves passing through the water remove Q
residual debris especially from threads and grooves which ~
=
IJ
-
may be difficult to clean manually.
=
~
- Only instruments of similar metallic composition should be ~
placed together in this machine. ·;=

- If there is any damage to the surface of chrome-plated instru- :?!
"C
..u=
ments, ultrasonic cleaning may cause further damage. ~
- Normal rinsing must follow this process. ~

~
399
•
(Delicate and sharp instruments are withheld and should be
cleaned manually.)
Once the mechanical cycle is complete, instruments are
checked for cleanliness and should be rewashed if necessary.
Mechanical cleaner units must be cleaned regularly on the in-
side and serviced as recommended by the manufacturer.
Note: Under no circumstances should any of the surgical power
equipment be cleaned mechanically.
Manual Cleaning
Warm water with the appropriately diluted cleaning solution or

detergent is used. The correct equipment should be available:
- A selection of soft nylon brushes.
- Air jet and nozzle.

- Clean compressed air supply with a single hose or double
hose and special connector.
Steel wool and abrasive cleansers must never be used. They
would scratch the surface of the instruments causing permanent
damage to the passivation layer.
If excessive blood or debris has coagulated on the instrument, it
"' may need to be soaked before cleaning. The instruments should
g.
~
be placed in a blood-dissolving detergent for approximately
·a 10 min (or according to instructions).
-=
~
~
"C
;
--=
=
.~
~
e
~
-...="'
-
:I
• 400
Special attention must be given to hinges, threads or hollow
parts on instruments. Blood, water or other residue can lodge in
these areas.
Instrument trays and cases must be cleaned following use. The

manufacturing material of the case or tray will influence the
cleaning procedure.
Stainless Steel Trays and Cases

The pegs and brackets for holding instruments in position need
not be removed for cleaning. The trays may be washed and
dried in a similar manner to stainless steel instruments. Re-
placement pegs with a special inserter, as well as tray dividers,
are available.
Aluminium Cases - Graphic Cases

This anodised aluminium must be treated cautiously (see Sect.
--
6.22.4.2). c
·=
~
c~
s
2
-...
.-
"c'
0
~
c
-
Cases with Rem ovable Lids ~
c
~
The pin holding the lid in position should be removed. Any re- c
·;
movable tray in the case is washed separately. Once all areas ~
have been dried thoroughly the case is reassembled, lid pin rein- "C
c
~
serted and hinges lubricated.
~
u
~
401
•
6.22.4.4 Rinsing After Cleaning
It is necessary to clear instruments of any residual cleaning solu-

tions or debris.
- Instruments must be rinsed under flowing water paying
particular attention to joints, threaded areas and hollow
parts.
- The quality of the rinsing water is important. Excessive min-
erals may be contained in the water leaving a scum on the sur-
face of the instrument. If neglected this can eventually lead to
pitting corrosion.
- Distilled water can also be used for the final rinse to clear all
remaining mineral residue.
- Rinsing is required following ultrasonic cleaning.
Note: If the water quality is suspected, it should be checked pro-
fessionally. Special filters or detergents may be recommended
to overcome this problem.
6.22.4.5 Drying
For drying instruments these guidelines should be followed:

- Each instrument must be dried thoroughly inside and out to
prevent rusting and malfunction.
- A soft cloth should be used to avoid damage to the surface.
- Special attention must be paid to threads, ratchets and hinges
or areas where fluid can accumulate.
- Open and close instruments so that all areas are reached.
- Hollow parts should be dried using the air jet. Attached to a

compressed air supply, this device allows air to be blown un-
der pressure through the instrument drying the inside. High
cleanliness of the air must be assured.
- A drying cycle is included in most mechanical washers. If not
included the preceding instructions should be followed.
"'
=
~
=" Note: If the instruments are to be used immediately and ster-

·a
'5 ilised without packing then drying is unnecessary.
~
"C
=
1::
=
-=e=
0
·.;
.=
~
....
-
~
• 402
6.22.4.6 Lubrication
If an instrument has a movable part it must be oiled after each

use to maintain its correct functional mobility. This also helps
prevent rusting. Instrument lubricating solution is one method
that can be used. The cleaned, rinsed instruments should be im-
mersed for the recommended period in the solution. Rinsing is
not required and once dried the instruments can be packed. This
process may also be incorporated in the cycle of some instru-
ment washing machines.
The manufacturers of AO/ASIF instruments also recommend
the use of nonsilicone SYNTHES oil for lubrication. This spe-
cific antimicrobial oil allows steam penetration during autoclav-
ing thus ensuring all areas will be sterilised.
The following areas are oiled:

- Joints, hinges, box locks or any mobile parts on an instru-
ment.
- Ball bearings present in instruments that have a rotating sec-

tion. The instrument must be disassembled.
--=
.s=
~
e
~
-..........==
' IJ
Q
~
=
~
-
~
- Those with threaded parts that open and close. =~
·;=
~
"C
=
~
...
~
u
~
403
•
One or two drops of oil are placed on the appropriate part. The
instrument is assembled and tested for function. This move-
ment also helps spread the oil and any excess oil should be re-
moved using a soft cloth. Too much oil may cause seepage
through the "wrapping" during autoclaving. This can lead to
contamination of the sterile contents.
Note: In ultrasonic cleaning all lubricant is removed therefore
particular emphasis must be placed on lubrication following this
cleaning method.
Certain items in the AO instrumentation should not be lubricat-
ed, e. g. radiolucent drive or unifix. (Please see Sect. 6.22.5 for
further information.)
The hinges on the pop-up rack for holding drill bits and taps
should be lubricated using SYNTHES oil.
• 404
6.22.5 Complex Instruments
Outlined here are some frequently used, more complex instru-

ments with specific reference to their care and maintenance.
6.22.5.1 DHS/DCS Triple Reamers
During surgery:
- Check that the sterile instrument is assembled correctly.
- The circle on the outside of the reaming segment follows the
groove of the drill. It cannot be locked unless it has "clicked"
into the correct position.
- The reamer is flushed immediately after use to prevent any
debris coagulating on the inside.
- Care must be taken when handling the sharp reamer as gloves

can easily be torn. Handle it correctly!
Following surgery:
- It must be dismantled before the normal cleaning procedure
is followed. Particular attention is paid to the threads and can-
nulated parts. Ensure that a guide pin is not jammed inside
the cannula.
- All parts are dried using the air jet for hollow parts.
- One or two drops of oil are placed on the threaded area and
the reamer is opened and closed to disperse the oil. Excess is
gathered on a cloth.
- The drill is checked for sharpness and may be sent to the man-
ufacturer for resharpening providing it is undamaged (see
Sect. 6.22.10).
405
•
- For sterilising, the instrument can be left apart or loosely as-
sembled.
6.22.5.2 Flexible Shafts and Reamers
During surgery:
- To prevent damage to the patient and to the reamers it is im-
portant that they are used sequentially in 0.5 mm increments,
changing the shafts when appropriate.
- Following use, the reamer head should be removed, wiped
and returned to its allotted place. Turning it upside down on
the peg will give an indication of the previous size used.
- The flexible shafts must be flushed using Ringer's lactate so-

lution or saline. This prevents blood or bone debris coagulat-
ing on the inside of the shaft before the final cleaning can take
place. The instruments must not be left to soak in these solu-
tions. In certain countries sterile water is used as a rinsing so-
lution. Care must be taken that this does not enter the wound .
• 406
Following surgery:
- The flexible shafts should be cleaned manually using a water
jet, nozzle and cleaning solution. The solution can be forced
through the wire walls by putting a finger over the distal open-
ing. This should be carried out under water to avoid spraying
of personnel.
- By flexing the shaft back and forth it is possible to dislodge
any residual debris.
- The air jet should be used for drying the shaft using the com-
pressed air supply.
- Reamer heads are washed thoroughly, dried, checked for

sharpness and replaced in their correct position.
- Reamer heads should not be resharpened, they must be re-
placed. With prolonged use or unauthorised sharpening the
diameter of the reamer head may be diminished.
6.22.5.3 Inserter-Extractor for Angled Blade Plate
--
During surgery: c
- To fix the plate to the inserter-extractor, it is laid flat on the .~
instrument table. ~
..-;;e=
- Tightening should be done using the combination wrench and ~
-
not the hexagonal screwdriver.
c
....
=
~
Col
c~
-c
c
·;
~
~
"C
c~
.
u
~
407 •
Following surgery:
- The instrument is disassembled for cleaning.
- Special attention is paid to the threaded part.

- Before replacing it in the set it is checked for wear. If the
threads are damaged it will not grip the plate correctly.
- A light lubrication is needed on the mobile threaded part.
6.22.5.4 Cannulated Screw Instruments
During surgery:
- Once the cannulated instruments have been used residue
should be cleared from the inside. A special stylet is available
to help dislodge any debris.
- Flush the instruments with Ringers lactate solution or saline
to keep them clear. In some countries sterile water is used as a
rinsing solution. Care must be taken that this does not enter
the wound.
- Excessive force should not be applied to the instruments.
- The appropriate uncannulated hexagonal screwdriver is used
for the final tightening of screws once the guide wires have
been removed.
• 408
Following surgery:
- Cleaning is carried out directly following the procedure.
- The stylet is used to clear any debris. A special brush is also
available to assist with cleaning. This is made from auto-
clavable nylon and steel material.
- Use of the air jet simplifies washing and drying of the instru-
ments.
- Both inside and outside the instruments must be completely
dry before checking, packing and autoclaving.
- The guide pin can be easily damaged so examine it carefully
and replace if required. This is frequently necessary following
each procedure. Since some are colour coded the appropriate
pins should be assembled with the correct set.
- All other instruments are also checked.
6.22.5.5 External Fixators
During surgery:
- Check that all clamps are correctly assembled before mount-
ing them onto the tubes.
409 •
Fallowing surgery:
- Once removed the clamps must be dismantled, decontami-
nated, cleaned and dried.
- They must be examined for possible damage. Damaged
threads would prevent the clamp from maintaining stability
while in use. They need to be replaced.
- Lubrication of the mobile parts is required.
- Clamps are reassembled.
- The tubes are washed and dried in a similar manner before

the set can be restocked and repacked.
- Caution is necessary when cleaning the case made of an-
odised aluminium (see Sect. 6.22.4.2).
Any Schanz screws that are removed from the patient are not
to be reused and should be discarded. An adequate stock of
new Schanz screws should be available to replace in the set.
• 410
6.22.5.6 Unifix
During surgery:
- The ball clamps are tightened by hand initially.
- A position change should not be done forcefully.
Following surgery:
- Once the unifix has been removed from a patient, it must be
completely dismantled for cleaning.
- A combination wrench and hexagonal spanner are necessary.
- The internal hexagonal bolts need not be removed for clean-
ing.
- This procedure is carefully observed to enable reassembly
afterwards.
- As the surface of the ball clamps is sand-blasted, it can even-

tually become worn and the ball clamp should be replaced.
Note: No lubrication is required and might even impair its sta-

bility.
=
--=
.~
~
-..=
=
~
....=
' ll
....
Q
~
=
~
-=
~
·;=
~
"CC
..u=
~
~
411
•
6.22.5.7 Bolt Cutter
During surgery:
- Before using the cutter, check its assembly. The teeth on the
cutter head must engage fully.
- The hole in the sleeve must be aligned with the hole in the cut-
ter head. It may be necessary to rotate the sleeve until the
holes are centred.
Following surgery:
- The cutter head must be disassembled completely for clean-
ing.
- The holes in the sleeve and body are aligned and the lock is re-
tracted. This will allow the nut to be unscrewed.
- The sleeve is removed and the components should be washed,
paying particular attention to the threads and hollow parts.
- Once dried, it is lubricated and the excess oil is wiped off. Ad-
equate lubrication is essential to ensure smooth cutting.
- It can be reassembled before autoclaving leaving the nut
loosely tightened.
- The groove on the sleeve is aligned with the screw on the body
"'~ of the bolt cutter head.
·2' - The handles are cleaned in the usual manner.
-=
~
~
"C
;
--=
=
.~
~
e
~
-...="'
-
:I
• 412
6.22.5.8 Suction Device
During surgery:
- The device should be flushed through to prevent coagulation
,, of blood.
- The handpiece is made of anodised aluminium so the usual
precautions are necessary (see Sect. 6.22.4.2).
Following surgery:
- The valves should be removed for cleaning
- All metal suction nozzles and the suction tubing must be
washed thoroughly. This is best done manually. A soft nylon
brush is available for this purpose.
6.22.5.9 Plate Benders/Pliers
During surgery:
- Note the possible positions of the pliers and benders.
- The handle of the plate benders must be in the neutral posi-
tion before commencement.
--=e
Following surgery:
- The plate benders and pliers are disassembled for cleaning.
=
.~
- Particular areas that may harbour residual cleaning solutions ~
need to be examined. Q,l
- The air jet can be used for drying these difficult areas once 2
they have been rinsed.
-=
'til
'0
Q,l
=
1.1
-=
~
Q,l
·;=
:t
-==
~
~
~
u
413 •
- Lubrication is important to maintain optimum function.
- Open and close to disperse the oil.
- Collect any excess.
Reassembling:
- The block in the benders makes contact in one position only.
- The locking bar in the pliers must be inserted fully to allow it
to function.
6.22.6 Preparation for and Sterilisation of

AO/ASIF Instruments and Implants
Malfunctioning or damaged instruments may be hazardous to

patients and personnel and should not be used., e. g. a blunt drill
bit may cause bone necrosis or a damaged screwdriver could
destroy the screw head making screw removal difficult if not
impossible.
6.22.6.1 Inspection
Before packing, each instrument should be inspected.

- Sharp instruments need to be examined using some magnifi-
cation otherwise it may not be possible to detect damage to
the cutting edge. See alsop. 61.
• 414
- Disassembled parts must be reassembled correctly with all
components.
- Instruments should be checked for correct alignment and

function. Open and close joints, ratchets, etc.
The surface is examined for any scratches which may lead to

corrosion.
- Malfunctioning, broken, blunt or damaged instruments
should be removed and replaced by a verified one.
- Screws, nuts or bolts may work themselves loose. Ensure that
they are retightened or replaced.
6.22.6.2 Care of New Instruments
New instruments come individually wrapped. The label on the

package provides the following information:
- The article number corresponding to the number in the cata-
logue.
- Material used, e. g. stainless steel.
- Lot number - each batch of metal used has a number for easy
identification should a fault occur.
- On newer labels, a bar code is included for computerised hos-
pital inventories.
Since new instruments do not come presterilised, they must be
prepared for use. It is necessary to subject them to the same
cleaning routine as for used instruments, i.e. dismantling, de-
contaminating, washing, rinsing, drying, lubricating, sterilising,
packing and storing. Any plastic protective covers or plugs must
be removed prior to cleaning and sterilising.
415
•
The handles on some of the instruments are light tan colour
when new, e. g. hexagonal screwdriver or periosteal elevator.
They will turn a darker colour with repeated sterilising but their
function is not impaired.
6.22.6.3 Packing
An acceptable standard should be adhered to wherever items

are prepared for sterilising:
- Instruments which belong in a set are replaced in the appro-
priate case. A checklist should be used to avoid error.
- The graphic case allows easy positioning of instruments and a
quick check for completeness.
- Delicate or sharp instruments must be protected to avoid

damage if they remain loose in the set. In newer cases, drill
bits and taps can be held in a specially designed rack.
- Heavy instruments should not be put on top of delicate ones.
- Instruments with ratchets can be closed to first or second
notch.
- Some multiple component instruments may be loosely re-
assembled.
- Those with joints or screw closures remain slightly open to al-

low full steam penetration during sterilising .
• 416
Material Used for Packing
A variety of different materials can be used depending on the

availability in the area. Whatever is selected must comply with
certain requirements.
- It must completely cover the instruments and allow easy re-
moval when required.
- It must allow penetration and release of sterilising agents to

permit adequate sterilisation, aeration and drying of the con-
tents.
- It must provide a protection against micro-organisms, dust
and moisture during storage.
A sterility indicator placed inside each pack will confirm the
sterilisation of the contents. Tapes or strips that change colour
on the outside of the pack do not necessarily indicate sterility as
they may automatically change colour at a certain temperature.
The sterilising date and the contents must be noted clearly on
the outside of the pack.
6.22.6.4 Sterilisation Methods Recommended for AO/ASIF

All AO/ASIF instruments or implants used in a surgical proce-

dure must be sterile. Disinfection alone is inadequate and unac-
ceptable in preventing infection during surgical interventions.
Sterilisation is a process which destroys living micro-organisms
including resistant spore-forming ones. It is not, however, a sub-
stitute for cleaning.
- Steam sterilisation was in use by the end of the nineteenth
century and is still the most widely used method.
- Thermal sterilisation with steam under pressure (autoclave)
can be used for all AO/ASIF instruments and implants with
the exception of the air jet which does not require sterilisa-
tion.
417
•
- Different types of sterilisers exist. Manufacturers instructions
for recommended use of the autoclave must be adhered to.
Gravity Displacement Steriliser

Steam entering the chamber under pressure displaces the air in
the chamber downwards. The standard cycle for wrapped
items : 121- 123 oc at 15-17 psi, with an exposure time of 15-30
min. If the temperature is 131-133 oc at 15-17 psi, then expo-
sure time is 15-20 min.
Prevacuum Steriliser
Air is first evacuated from the chamber before the steam is ad-
mitted. This takes place during the prevacuum phase. The stan-
dard cycle for wrapped items: 132-135 oc at 27-30 psi with a
minimum exposure time of 4-10 min.
"Flash" Steriliser
This is a high-speed pressure steriliser most commonly with a
gravity displacement cycle. The instruments for sterilisation are
unwrapped. Its use is restricted to emergency situations, con-
taminated or forgotten items. The instruments are exposed to a
temperature of 132 °C. for a period of 10 min.
Note: Implants that will remain in the body must not be ster-
ilised in this manner as the sterility cannot be fully guaranteed.
It is advisable, and in some countries mandatory, to have a nega-
tive reading from the biological indicator used when sterilising
implants. This is displayed 48 h after sterilisation, and implants
~ may not be implanted unless this has been passed.
;. In an emergency situation if an implant is required it may be
·a
'S
sterilised unwrapped following the normal time and tempera-
~ ture scale for prevacuum or gravity displacement sterilisers. It
'1:l should not be used as a routine method of sterilising.
=
<:':1
.s:....=
-~
=
e
Q,j
......
:::)
.5
• 418
Table 1
Steriliser Temperature Pressure Exposure Time Wrapping
Gravity 121 °- 123 °C 15- 17 psi min. 30 min wrapped

displacement or 1-1.2 bar
steriliser 131 °-133 °C 15- 17 psi min.20min wrapped
Prevacuum 132 °-135 oc 27- 32 psi min.4min wrapped
steriliser or 2-3 bar
up to 141 oc 27-30 psi
Flash steriliser 132 °-134 °C 27- 30 psi 10min unwrapped
(gravity 2- 3 bar
displacement)
Hot Air Steriliser

Hot air sterilisation requires a longer exposure time and a high-
er temperature This prolonged exposure time may be haz-
ardous to certain instruments, e. g. lubricated instruments or
those with soldered parts:
- Temperature: 180-200 oc
- Exposure time: 30 min
Hot air sterilisation is not recommended for air-powered equip-
ment as prolonged use may damage the sealings.
Chemical Sterilisation
Ethylene oxide gas and formaldehyde gas are just two exam-
ples. Since it is unnecessary and not recommended to use a
chemical steriliser for AO/ASIF instruments, no further com-
ment is necessary (it may be used according to guidelines, if no
other method is available).
Sterilising
When loading the steriliser it is important to arrange the con-
tents so that all items will be fully sterilised. The general recom-
--==
mendations for autoclaving should be followed.
Once the process is complete the packages are allowed to dry
=
_g
fully before being inspected and stored.
A specific test for sterility is recommended for each type of ster- e
~
iliser. This should be done on a daily basis, to monitor its func-

tion. Any positive reading from the sterility indicator should be
reported and patients monitored for infection if items have
2
.-
-...=
"'
Q
been used from this load. ~
=
<:.1
-=
Regular cleaning and maintenance of the autoclave, according
to manufacturers instructions, is essential to maintain optimum
=
QJ
standards. A faulty autoclave may cause spotting or damage on ·;=

the instrument surface. ~
=
"C
=
~
u=
419
•
6.22.7 Storage of Sterilised Items
Before storing, all sterilised items must be thoroughly dry and

fully cooled. The pack is inspected for:
- Damage to outer covering.
- Any wet, damp or discoloured areas on the covering.
- Intact seals.
- Clear identification of its contents.
- Date and cycle number of sterilisation.
If there is any doubt, the pack is opened. It should then be
repacked and resterilised.
·~ c_v,.-..{
iho"z.e<'
'6.~.'\3
Certain criteria are required for the designated storage area:

- Adequate space, well-ventilated and away from excess traf-
fic, must be selected. It should be easily accessible when re-
quired.
- A closed unit is preferable, but open shelving may also be
used, particularly if items rotate frequently.
- A well-planned organised system will assist personnel in lo-

cating desired items efficiently.
- An area with high temperature or humidity should be avoid-
ed.
Note: Unsterile items should not be stored in the same locality.
• 420
Length of "Shelf Life"
This is dependent on the policy of the department and is not
necessarily time related. Factors which influence this are:
- Type of packaging material used.
- Method of sterilising.
- Storage area (open or closed).
- Frequency and amount of handling before use.
Therefore it is necessary that a department policy is established
to maintain optimum standards. A regular inspection should be
carried out to check the condition of items in storage. Any
"doubtful" items should be repacked and resterilised.
As yet there are no international standards available for accept-
able storage times. A European standard is expected to be pub-
lished in the near future.
6.22.8 Cleaning and Care of Implants
6.22.8.1 Implants
Before surgery:
- The anticipated, sterile, implants must be gathered for the
procedure. A full selection should be available.
- Correct preoperative planning by the surgeon will give an in-
dication of what is required.
- "Flash" sterilisation of implants is not recommended as steril-
ity cannot be guaranteed (see Sect. 6.22.6.4).
During surgery:
- Implants should remain covered until required to avoid con-
--
tamination and only those to be implanted should be han-
dled. .s=
- Minimal handling is necessary to prevent damage to the sur- =
=
face. e
~
- If a plate needs contouring a template should first be used on 2

the bone to determine the required shape. This avoids over
contouring or handling of the plate. -
~
....=
=
~
=
(.I
-=
~
=
=
·;
~
"C
=
=
...
~
u=
421 •
Following surgery:
- Contaminated implants must be placed in a separate recepta-
cle for careful washing by hand.
- Final rinsing should be with distilled water to ensure clear-
ance of mineral residue.
- A soft cloth should be used for drying to avoid scratching the
surface.
- The air jet can be used to dry the hexagonal recess in screw
heads.
- Templates are restraightened for further use.
6.22.8.2 Implant Cases
- Screw and plate cases should be wiped following use. Alcohol

can be used for this purpose.
- If inadvertently contaminated, full washing, as for instru-
ments and cases, is required. This should be done manually to
prevent the possibility of damage to the implants (see Sect.
6.22.4.3).
- Drying can take place in an autoclave before packing for ster-
ilisation. Manual drying is time consuming!
6.22.8.3 Restocking
- Implants must be rotated so those already in the set are used

first.
- Handling should be kept to a minimum, but if necessary the
use of gloves is recommended (see Sect. 6.1.1.2).
- The stainless steel "holding clip" should be used for smaller

plates. Ordinary safety pins are made of tin and may damage
the implants. Plates should not be "stacked" when replacing
in a set. In the graphic case one plate per peg is adequate.
Overstocking may cause surface damage to the plate and may
also prevent full steam penetration during autoclaving.
• 422
6.22.8.4 Reuse of Implants
Implants, which have been implanted and remained in situ,

once removed from a patient, should never be reused.
- Unused plates can be replaced in the case or their protective
wrapper once cleaned.
Tl - If a plate is contoured slightly during surgery but not used it
may be reserved for use at another time. Straightening the
plate is not recommended in order to identify a plate that has
already been altered.
- Provided it is undamaged, a screw which was implanted and
immediately removed can be washed, dried and replaced in
the set or otherwise discarded.
- The anchoring screw used with the tension device should not
be reused as it has been stressed during the compression/dis-
traction procedure.
6.22.8.5 New Implants
All implants should remain in their protective wrappers until re-

quired for sterilisation to protect them from damage or grime.
Implants should be removed from their packets prior to auto-
claving.
Washing of implants before use is now required. Following pro-
duction, the implants undergo a surface-finishing procedure.
This results in a high state of surface cleanliness as a layer of ma-
terial is removed from the implant, e. g. electropolishing of
stainless steel implants. This surface cleanliness however can-
not be guaranteed during further handling, secondary inspec-
tion or packaging procedures. Although optimum care is taken
to avoid any contamination during the finishing process wash-
ing of implants before use is recommended. Once removed
from their packets they are cleaned in a similar manner to con-
taminated implants. The use of gloves is recommended when
--=
handling the implants to avoid damage to the surface. The new
implants can then be sterilised according to normal policy for .:==
implants. On special request some items may come already ~
presterilised directly from the manufacturer.

e
-
~
E
"....'
6.22.8.6 Labelling/Packaging ...=
Q
Q,j
=
~
-
Screws come in individual or multiple packs. Other implants, ~
e. g. plates or nails come individually packaged. The label on the =

Q,j
packet provides details of the contents. ·;=

~
-==
I
~
~
~
u
423
•
6.22.9 Cleaning and Care of Power Equipment
Inadequate maintenance of power equipment is a pnmary

cause of its malfunction.
6.22.9.1 General Guidelines
Compressed air (or nitrogen) can be used as a power source (see

Sect. 6.21.1). Oxygen must never be used because of the danger
of explosion or fire.
During surgery:
- The machine and air hose should be suitably placed to main-
tain sterility at all times. If the hose is too long, there is a
greater risk of contamination.
- Once it has been connected and the required attachment
mounted, its function must be verified before use on the pa-
tient.
- The rotor may not start immediately resulting from sterilisa-
tion or if it has not been used for some time. To assist a start,
the coupling should be rotated manually and the trigger
pressed to release the motor. This should be done with cau-
tion to avoid injury.
- Power equipment should be fully cooled before it is used, fol-
lowing sterilisation, otherwise the seatings may be damaged
or the air hose could burst.
In emergency situations only, a partially cooled machine can
be further cooled by running the compressed air through it.
- Avoid handling the machine with blood-covered gloves. Re-
move any excess blood before it coagulates.
Following surgery:
- As with instruments, the machines, hoses and accessories
must be cleaned as soon as possible after use. All attachments
are removed and they can then be washed manually.
Note: The machines should never be immersed in water or
washed in a machine.
- A soft nylon brush should be used, under running water, tore-
move any debris. This also applies to the couplings and other
~"' areas on the machine.
=
="
·a
.= Caution: Water must not be allowed to enter through the air in-
"
~ let. If this inadvertently occurs the machine should be removed
2! immediately and the water allowed to drain out. It can then be
: connected to a single hose (or double hose and special adapter)
.g attached to compressed air. The machine should be run until all
~ the water is expelled which may take 30-40 s. Lubrication must
e~ follow. The machine should be checked by the manufacturer as
,5 soon as possible, as any moisture trapped inside can eventually
.,5 destroy the mechanism.
• 424
6.22.9.2 Air Hoses
They are available as double hoses or single hoses (see Sect.

6.21.2).
- Water must not enter the hose therefore manual washing is
required.
- Using an appropriate cleaning solution the hose can be im-
mersed. The coupling ends must be protected and should re-
main out of the water.
- Some ends may be coupled (SYNTHES) and can be fully im-
mersed.
- The couplings can be cleaned using a nylon bush.
- Lubrication of the coupling end is required but oil should not
enter the hose itself.
- If water enters the hose compressed air should be blown
through until all residual water is expelled.
6.22.9.3 Rinsing/Drying
Once rinsed the machines and hoses must be dried thoroughly.
6.22.9.4 Lubrication
Air machines and air hose couplings must be lubricated after

each use. The special SYNTHES oil is recommended. Approxi-
mately ten drops of oil must be inserted through the air inlet
pressing the operating trigger at the same time:
- The machine should be attached to a single hose (or double

hose and special oiling adapter, which prevents the oil enter-
ing the lumen of the hose). It can be connected to the air sup-
--=
.2=
~
a.
e
ply and run for 20-30 s or until no oil is visible. This will dis-
perse the oil in the turbine. Hold a cloth around the air outlet
to collect any excess oil.
-
2
....=
r iJ
....
Q
- If the oil appears dirty the procedure has to be repeated. a.
=
IJ
=
~
a.
=
·;
~
"C
=
..
u
~
a.
~
425 •
- Couplings on air machines and hoses, when lubricated,
should be moved back and forth to spread the oil.
- Triggers have to be depressed and released.
- A few drops of oil in each of these areas should be adequate
and any excess oil can be wiped off.
6.22.9.5 Small Air Drill
Clean as directed. The following parts should be lubricated:

- Air inlet.
- Triggers.
- Quick coupling
Adapters and Accessories

- Oscillating drill attachment:
Clean as directed. Lubricate the ball bearing at connecting
point.
~"'
=
·a="
-=
~
~
"C
=
--==
eo::!
.::=
e
~
-..."=='
-• 426
.... ·..
, ;
- Radiolucent drive:
Clean as directed.
--------
It is important to clean immediately after use.
It can be disassembled into two parts by depressing the but-
ton and pulling apart.
Once it has been dried, it can be reassembled in reverse se-
quence ensuring the button has fully engaged in the hole.
No lubrication is required.
For sterilisation, autoclave up to 134 oc only.
Do not use until fully cooled.
Note: Instructions for use should be carefully followed to avoid
damage. When properly operated and cleaned the radiolucent
drive does not need daily maintenance. A check-up by the man-
ufacturers following use for 100-150 times or 1 year is recom-
mended.
- Jacobs chuck and key and
- Small quick coupling chuck:
Clean as directed, but particular attention must be paid to
areas that could harbour debris.
For lubrication, put a few drops of oil on the threaded por-
tion. The chuck should be opened and closed to disperse
the oil. Ensure that the teeth on the chuck and key are
undamaged.
6.22.9.6 Universal Air Drill
Clean as directed. The following parts should be lubricated:

- Air inlet
-Trigger
- Quick coupling
--e=
=
-~
~
llJ
--.==..'"'
"'
Q
~
~
=
-
~
=
llJ
·;=
~
'C
=
~
~
u
'"'
~
427
•
- Right-angled drive:
Clean as directed, paying particular attention to cannulation
for reaming rod.
Lubricate the quick coupling and locking screw.
- Quick coupling chuck:
- Small quick coupling chuck:
- Universal chuck:
- Jacobs chuck and key:
Clean and lubricate as directed.
6.22.9.7 Oscillating Bone Saw
Clean as directed. The saw blade housing plate must be re-

moved for cleaning. Using two Kirschner wires, the plate can be
lifted and removed. It is washed and dried. If the pins are dam-
aged they must be replaced by new ones. Under slight pressure
they will click back in position. The following parts should be
lubricated:
- Airinlet
- Operating lever
- Pin under lever
- Locking mechanism on lever

- Saw blades :
~ Replace if they are worn or damaged.
S. - Locking key
·a
.cAll the adapters and accessories should be checked in the ap-
u
~ propriate machine before packing and autoclaving.
't:l
c
1::
c
-a=
.:=....
cQ,j
.......
~
!
• 428
6.22.9.8 Mini Compressed Air Machine
Clean the compressed air motor as directed. Lubrication should

be carried out as follows:
- With the special oiling adapter attached to the drill put ap-
proximately 8-10 drops of oil into the air inlet.
- Connect the machine to an air hose and compressed air and
use it to disperse the oil.
- Gather any excess oil on a cloth.
- The drive switch on the drill must also be lubricated.
Accessories
- Mini oscillating saw
- Mini reciprocating saw
- Drill head attachment straight
- Drill head attachment 90 o
- Drill head attachment 45 °:
This has a special cleaning brush.
- Angled hose connector
- Drill bits
- Burrs
- Saw blades:
Tissue protectors and saw blades should be washed in the usu-
al manner. Any worn or damaged blades must be replaced by
new ones as they cannot be sharpened.
All attachments must be washed, dried and lubricated where
necessary before being verified and replaced in the special case
provided. The anodised aluminium case should be cleaned (see
Sect. 6.22.4.2).
- Double air hose :
This should be treated in the same way as all other hoses (see
Sect. 6.22.92). When packing it into the set it should not be
--==
=
.~
e
-=e
~
folded tightly. It is stored underneath the instrument tray and

should not come in contact with the metal contents of the set.
...."'
'0
~
=
(.J
-=
=
=
~
·;
~
"0
=
..
=
~
u=
429 •
6.22.9.9 Preparation and Packing of Air Equipment
for Sterilisation
The standard guidelines for packing and sterilising also apply

(see Sects. 6.226.3 and 6.22.6.4):
- The hose must not come into contact with metal. If a special
tray is not available to separate the motor and hose, they
should be wrapped individually.
- Ensure that no material that may be affected by high temper-
atures is left on the machine, e. g. the plastic stopper in the air
inlet of new machines.
- All accessories must be removed before packing.
- The hose ends should not be coupled for autoclaving. This
may cause jamming of the couplings and bursting of the hose.
- A gentle coil for straight hoses is appropriate.
Spiral hoses can be held in place for autoclaving using a cloth
bandage or nonadhesive tape.
- The machines and hoses can be sterilised by thermal sterilisa-
tion (see Sect. 6.22.6.4). Radiolucent drive to 134 oc only.
- Hot air sterilisation is not recommended for the power equip-
ment as it may damage the sealing on the machine. Also
sterility cannot be fully guaranteed as the air may not fully
penetrate all parts of machine.
- Flash sterilisation can be used provided the exposure time
and temperature is adequate. (Independent testing was car-
ried out in the USA which confirmed that under the correct
conditions all areas of the air machine were sterilised.) (See
Sect. 6.22.6.3).
- No heavy weight or pressure should be placed on the hose es-
pecially during sterilisation or cooling. It may cause perma-
nent deformity of the hose.
- The air-powered instruments should be used only when fully
cooled. Hoses may otherwise deform or become brittle and
leak and the sealing in the machine itself may be damaged if
used while still hot.
"'
~
·2'= 6.22.9.10 Cleaning and Maintenance of Diffusor, Filters

'5 and Pressure Regulators
~
-=c For details see Sect. 6.22.1.3.
c= - Exhaust air diffusor:
....
.~
This is fitted between the single air hose from the supply and
....=
e=
~
the double sterile "working" hose. It can be unscrewed to
......=
take apart for cleaning. As it is made of anodised aluminium,
-
the usual precautions are necessary (see Sect. 6.22.4.2. and 3)
"'c
• 430
- Filter cartridge:
This is changed when the air drill is noticed to be losing power.
- Filters for air supply:

- Coarse filter and micro filter:
As both these filters render the air free from water, condensa-
tion, rust or other particles it is necessary to clean them re-
gularly- every 2 weeks is the recommended practice.
The air supply must first be shut down and then the filter can
be dismantled.
The outside and inside of the protective glass must be
cleaned. The air filter element must also be cleaned with a
long term anti-bactericidal spray.
Along with the cleaned connections the glass should also be
sprayed with this anti bactericidal spray.
Once a noticeable reduction occurs in the speed of the ma-
chine or following use for 1 year the filter element should be
changed.
6.22.10 Repair Service
To use a damaged, blunt, or broken instrument on a patient is a

dangerous practice. It is the responsibility of the operating
room personnel to ensure that any such instruments are re-
moved and not available for use (see Sect. 6.22.6). Depending
on the severity of the damage certain items in the AO/ASIF in-
strumentation may be repaired. As it would be impossible to
mention each item individually always check with the supplier
who can advise on the repair service available for that region. Ir-
reparable damage can be done to instruments by unqualified
handlers. Whenever possible instruments should be sent to the
manufacturer for repair.
431 •
As stated at the beginning of the chapter, misuse of instruments
is one of the major causes of damage. Perhaps by studying the
information carefully in this book along with the other litera-
ture which is available, the repair service can be diminished!
6.22.11 Handling of Retrieved Implants
There may be reasons for the return of retrieved implants for

examination (for example breakage of an implant). Great care
should be taken that the implant is not damaged during han-
dling and shipping. Fracture surfaces of implants, or implant
parts of special interest, should not rub against each other. In
general retrieved implants should be handled as if they were
contaminated by infectious micro-organisms.
Retrieved implants should be rinsed under flowing water to re-
move blood and exudates. Scrubbing, however, is not allowed,
because areas of interest for investigation could be damaged.
The rinsed implants may or may not be sterilised. Either condi-
tion should be declared with a label on the package. Nonster-
ilised retrieved implants should be packed in such a way that po-
tential infection is prevented.
The retrieved implants, shipped for investigation, should be
clearly identified: the hospital, the surgeon, the name and/or
identification number and age of the patient, the implantation
site, and the reason for return of the retrieved implant should be
stated. In most instances it is highly desirable to obtain X-rays
and the patient's history with such information as:
- Diagnosis
- Date of implantation
- Date of retrieval
- Complications
~ - Postoperative loading history
6- - Brief patient postoperative history
·a
'5 If tissues are excised and shipped with the implant they should
~ be transferred immediately to a fixing agent like formalin or
'C
=
~
80% ethanol. The tissues should be clearly identified with the
location site and orientation described. The container and all
=
-;;· wrapping should be secure and ensure that damage to the con-
....
= tainer and the specimen is prevented.
e
......=
~
.s"'
• 432
6.22.12 Handling of Damaged Instruments
The same rules in general apply to the handling of instruments

to be returned for examination. However, sterilisation should
always take place and should be indicated on the package. Clear
identification is also important with instruments. The accompa-
nying information should indicate:
- Reason for return
- If damaged, when, where and in which way did it occur
- Which surgical procedure was performed
- How long the instrument was in use
6.22.13 References
AORN standards and recommended practices for perioperative nursing

(1992) Association of Operating Room Nurses, Denver
Deutschsprachiger Arbeitskreis fiir Krankenhaushygiene in Zusammen-
arbeit mit der AO-International (1992) Krankenhaushygiene. mhp Ver-
lag, Wiesbaden
Gruendeman BJ, Meeker H (1987) Alexander's care of the patient in
surgery. Mosby, St. Louis
ISSM (1990) Teaching and training manual for sterile service personnel.
Working Group- Supplies Service, Northampton
....=
.~
....=
e=
.
Q;j
....=
- "'
....=
=
Q;j
=
~
=
....=
Q;j
·;=
~
=
"CC
=.
~
u=
433
•
7 Internal or External Fixation
of Various Fractures
By R. Texhammar
In the following section some fractures and possible treatment

using AO/ ASIF technique will be discussed. This is meant to be
used as a reference and a guide by the operating room person-
nel, once the surgical decision has been made to stabilise a frac-
ture operatively. It may help the reader to perform her or his
task with more confidence.
7.1 Fractures of the Scapula and the Shoulder Joint
Fractures of the scapula may be found in polytraumatised pa-

tients, although they may also be seen as isolated injuries. They
are in most cases only minimally displaced and rarely require
surgery. Severely displaced and unstable fractures of the neck,
acromion or occasionally the coracoid process are indications
for surgery. Often these fractures are associated with a fracture
of the clavicle (see Sect. 7.2).
-
·s...,=
....Q,j
"C
'3
0
-=
rl)
"C
=
=
=
'3
=-
=
(j
rl)
435
•
7.1.1 Anatomy
Left clavicle, scapula and humerus, from the front (Fig. 1 a).
Left scapula and humerus, from behind (Fig. 1 b).
Sternal (medial) end Acromial (lateral) end
Clavicle
.:lo---r- Coracoid process

Glenoid cavity
Head
Anatomical neck
Greater tuberosity
Lesser tuberosity
...._---,-- Bicipital groove
Surgical neck
Shaft
Deltoid tuberosity
Inferior angle
Humerus
Coronoid fossa
Lateral epicondyle
Capitulum
Coracoid process
1a Trochlea
Superior angle
Head - - rr--
Anatomical neck
Greater tuberosity
Surgical neck
Medial border
Radial groove
-=...=
..."'
Col
Deltoid tuberosity
IJ
"'e= Humerus
·;::::
...~e
.2=
-
~
~
Olecranon fossa
Lateral epicondyle - -
•
Medial epicondyle
Capitulum --~.......--...,..,-"'-/
436
Trochlea
7.1.2 Assessment
Special examination:
- In multiply injured patients, check for thoracic and brachial
plexus injuries.
Radiography:
- The antero-posterior (AP) view, angled perpendicular to the
blade of the scapula, and the profile tangential views are stan-
dard.
- Acromio-clavicular joint: AP views of both joints are taken
separately and the beam angled up 15 o if necessary. Load-
bearing views, with a weight in each hand, may reveal vertical
instability.
- Shoulder: AP and axial views are standard. If the injury pre-
cludes the axial view, the Wallace and Heller view (Radiogra-
phy 1990), with the patient seated, is the most helpful.
7.1.3 AO Classification
Scapular fractures are grouped with the clavicle, the mandible

and the patella- bone group 9. The scapula is 9.1.3- the sub-
types and subgroups are not yet defined.
7.1.4 Indication for Osteosynthesis- Implants of Choice
Fracture:
- Displaced intra-articular fracture of the glenoid (Fig. 2).
Implants :
- 3.5 mm cortex screws or 4.0 mm cancellous bone screws as lag
screws (Fig. 3). Some such fractures extend into the lateral
border of the scapula and a small, infraglenoid, one-third
tubular plate may be applied to the lateral border as a buttress.
Fracture:
4 - Markedly displaced extra-articular fracture of the glenoid
neck (Fig. 4).
Implants:
- One-third tubular plate, 3.5 mm DCP, or LC-DCP (Fig. 5) for
the fixation of the clavicle may suffice.
437 •
7.1.5 Preoperative Planning and Preparation
Timing:
- Rarely urgent. Determined by the need for other surgery and
the patient's general condition.
Position:
- Prone or lateral with the arm supported. The arm is draped to
be freely moved.
Incision:
- For fractures of the posterior aspect of the glenoid as well as
of the lateral margin of the scapula, a curved skin incision
starts at the palpable lateral prominence of the acromion,
passes medially along the scapular spine and then caudally to
end at the inferior angle of the scapula (Fig. 6).
- For fractures of the anterior and inferior margins of the
glenoid, the delto-pectoral approach may be chosen. See Fig.
15 in Sect. 7.3. 1 Clavicle
2 Acromion
Preparation of instruments: 3 Greater tubercule
- Instruments for insertion of 3.5 mm cortex screws as lag 4 "Spinal triangle '"
screws (p. 215). of spine of scapula
5 Inferior angle
- Instruments for insertion of 4.0 mm cancellous bone screws 6 Suprascapular nerve
as lag screws (p. 214). 7 Axillary nerve
- Instruments for application of 3.5 mm DCP or LC-DCP
(pp. 215, 216).
- Instruments for application of one-third tubular plate (p.
216).
7.1.6 Checklist for Operative Technique
Posterior approach in extra- or intra-articular fractures:

- Exposure and detachment of the deltoid muscle from the
scapular spine and retraction laterally.
- The approach is deepened by developing the interval be-
tween infraspinatus and teres minor.
- Reduction can be achieved using pointed reduction forceps.
- Application of 3.5 mm DCP or LC-DCP (pp. 202, 208).
- Application of one-third tubular plate (p. 200).
- Application of 4.0 mm cancellous bone screws as lag screws
(p. 195).
Anterior approach in fractures of the glenoid :
- Reduction of inferior glenoid fractures can be difficult.
- Osteotomy of the coracoid may be necessary for improved
exposure. Later reattached with 4.5 mm cortex screw and
polyacetate washer to prevent splitting of the coracoid tip.
• 438
7.1. 7 Special Consideration- Escape Routes
Where access to the lateral border ofthe scapula is required, the

more extensive Judet approach, where the belly of the in-
fraspinatus muscle is reflected laterally to expose the whole in-
fraspinous fossa, may be indicated.
7.1.8 Postoperative Care
- Suction drainage for 24-36 h.

- Temporary immobilisation in a Gilchrist or Desault bandage
for 3-4 days followed by careful passive and active motion.
7.1.9 Implant Removal
Implant removal is difficult and rarely indicated.
7.1.10 Recommended Reading
Muller ME, Allgower M, Schneider R, Willenegger H (1991) Manual of in-

Riiedi T, Hochstetter AHC, Schlumpf R (1984) Surgical Approaches for
Internal Fixation. Springer, Berlin Heidelberg New York
Schatzker J, Tile M (1987) The rationale of operative fracture care.
Springer, Berlin Heidelberg New York
-
·=.,.=
~
::5!
-==
r:I:J
"CC
=
-==-=
=
y
r:I:J
439
•
7.2 Fractures of the Clavicle
Most clavicular shaft fractures usually heal without immobilisa-

tion and are therefore treated conservatively. Nevertheless, in-
ternal fixation may be chosen for the following indications:
- Open fractures
- Fractures associated with neuro-vascular lesions
- Fractures combined with scapular neck fractures - the im-
ploded shoulder
- Fragment threatening to perforate skin
- Fractures associated with an apical pneumothorax or surgical
emphysema
- Severely displaced fractures
- Pseudarthroses
7.2.1 Anatomy
Left clavicle and scapula from the front (Fig. 1).
Sternal (mediaQ end Acromial Oateral) end
Clavicle
Medial border - - - 1
7.2.2 Assessment
- Inspection of skin.
- Palpation for surgical emphysema.
Radiography:
- Standard view, look for pneumothorax or surgical emphyse-
ma.
With patient supine, two films at 90 a to each other are taken
with the overhead beam centred on the clavicle.
See Sect. 7.1.3. The 9.1.2 subtype groups are not yet defined.
• 440
___J 7.2.4 Indication for Osteosynthesis- Implants of Choice
Fracture:
- Midshaft fracture (Fig. 2).
2
Implants :
- 3.5 mm reconstruction plate (Fig. 3).
- 3.5 mmDCPorLC-DCP.
Fractures:
- Unstable displaced fracture - lateral end (Neer classification,
type 2) (Fig. 4).
Implants:
3 - Small T plate (Fig. 5).
- Tension band figure-of-eight wire.
Timing:
4
- Urgent if pneumothorax or neuro-vascular compromise.
Otherwise when the patient's condition is optimal.
Position:
- Supine with ample padding beneath the shoulder (vacuum
mattress).The arm is draped free. The head is turned toward
the opposite side.
Incision:
5 - A sabre cut incision running parallel to Lange's lines usually
gives adequate access (Fig. 6).
Preparation of instruments:
- Instruments for application of 3.5 mm reconstruction plate
(p. 216).
- Instruments for application of 3.5 mm DCP and LC-DCP
(p. 215, 216).
- Instruments for application of small T plate (p. 216).
- Instruments for application of tension band wire (p. 369).
6 - Temporary reduction with a pointed reduction forceps.

- Aluminium template is contoured to the bone, the plate is
1 Clavicle
2 Acromio-clavicular joint
shaped and then trial fit to bone. The plate may be placed on
3 Acromion the anterior or superior aspect of the clavicle. A seven- to
4 Conoidal ligament eight-hole reconstruction plate is chosen (p. 213).
5 Trapezoidal ligament
6 Coraco-acromial ligament
- Fixation of a lateral clavicular fracture with a small T plate
7 Coracoid process (p. 212).
441 •
7.2.7 Special Consideration- Escape Routes
The oscillating drill is safer in this area. Because of the proximi-

ty of vital structures deep to the clavicle, overpenetration of the
drill bit must be avoided; a bimanual hold on the drill, with the
nondominant hand exerting counterpressure, is relatively safe.
If there should be any question of puncture of the lung, the
wound should be filled with Hartmann's or Ringer's lactate so-
lution and the anaesthetist asked to hyperinflate the lungs. If
bubbles appear, a chest drain should be inserted and the patient
nursed for about 48 h in the intensive care unit.

- If fixation is stable, a simple supportive sling until wound
healing is assured.
The plate and screws often cause symptoms and may be re-
moved after sound bony healing at about 6-9 months.

Rtiedi T, Hochstetter AHC, Schlumpf R (1984) Surgical Approaches for
..=
-..
[IJ
~
1.1
~
fo;.
rl;
=
Q
'i:
...~·
Q•
=
Q
~~
lZ
• 442
Acromial (lateral) end 7.3 Fractures of the Proximal Humerus
Only a few fractures of the proximal humerus require osteosyn-

-l---r-- Coracoid process thesis. Surgical treatment is chosen mainly to treat markedly
Glenoid cavity displaced unstable fractures in young patients with good bone
Head
Anatomical nee~
Greater tuberosity
quality and in polytrauma patients. Internal fixation is often dif-
Lesser tuberos~y
.....~--r- Bicipital groove
ficult and presents a challenge to the surgical team.
Surgical neck
Shaft 7.3.1 Anatomy

1a
Coracoid process Proximal humerus and acromio-clavicular joint from the front
(Fig.1a).
Proximal humerus and shoulder joint from behind (Fig.1 b).
Head - '7"9'---
Anatomical neck
Grealer tuberosity
Surgical neck
1b 7.3.2 Assessment
- Neuro-vascular function of arm and hand.
Radiography:
- Standard AP view, axial view, and parasagittal view (posteri-
or dislocation?)
- Tomography
- Computed tomography (CT) scan
A A2
A3 7.3.3 AO Classification
See also Sect. 5.1
Type 11 A: Extra-articular fractures with one fragment

(tuberosity or metaphyseal) (Fig. 2).
Type 11 B: Extra-articular fractures with two to three frag-
93 ments (both tuberosity and metaphysis) (Fig. 3).
Bl 92 Type 11 C: Intra-articular fractures involving the anatomical
neck (Fig. 4).
c C2 CJ
443 •
Fractures type A:
- Fracture dislocation (Fig. 5).
- Displaced unstable fractures of the neck of greater tuberosity
(collum chirurgicum) (Fig. 6).
Implants:
- Cancellous bone screws, 4.0 mm or 6.5 mm (displaced avul-
5 6
sion fragments) (Fig. 7).
- Tension band wiring (Fig. 8).
- T plate, three or four holes (large head fragment) (Fig. 9).
Fractures types B and C:

- Displaced fragments in young adults (Figs. 10, 11 ).
Implants:
- Tension band wiring and 4.0 mm or 6.5 mm cancellous bone
screws (Figs. 12, 13).
- Kirschner wires percutaneously (Fig. 14).
7 8
Timing:
- Immediately, if skin and general condition allow.
Position:
- Supine with ample padding beneath the shoulder (e. g. vacu-
um mattress), arm abducted 45 o , patient's head turned to-
ward the opposite side. Arm draped free.
9
Incision:
- Anterior delta-pectoral approach in most cases. Posterior
approach for irreducible posterior fracture dislocations
(Fig.15).
- Instruments for insertion of 4.0 mm cancellous bone screw
(p. 214).
- Instruments for insertion of 6.5 mm cancellous bone screw
(p. 82).
- Instruments for application of cerclage wires (p. 369).
- Instruments for application of aT plate (p. 112). 10 11
• 444
Fractures type A:
- Atraumatic anatomical reduction, temporary fixation with
Kirschner wires.
- Insertion of 4.0 mm cancellous bone screws as lag screws
(p. 195).
13 (p. 81).
12 - Application of tension band wire with a 1.25 mm diameter.
cerclage wire (p. 366).
Fractures type B and C:
- Reflection of the deltoid muscle.
- For better exposure if necessary: anterior osteotomy of the
acromion.
In good bone:
- Anatomical reduction.
14 - Fixation with 4.0 mm or 6.5 mm cancellous bone screws
with washers as lag screws, combined with tension band wire
(pp. 81, 195). Sometimes 4.5 mm cortex screw as lag screws
(p. 77).
In poor bone:
- Impaction of the humeral shaft into the head fragment.
- Fixation with Kirschner wires 1.6 mm or 2.0 mm diameter,
and tension band wire (p. 366).
In multifragmentary fractures:
- Provisional or definitive fixation of smaller fragments with
Kirschner wires supplemented with a long T plate as a protec-
tion or buttress plate (p. 108).

1 Coracoid process
2 Acromion
3 Greater tubercule
Preservation of soft tissue attachment is mandatory. In poor
4 Clavicle bone, 6.5 mm cancellous bone screws may get a better hold. Ful-
5 A xillary nerve ly threaded screws are used in the head of the T plate.
."'
=
e
~
=
=e
';
..=
·~
=-..
445
•

- Partially abducted position of the arm (pillows or skin trac-
tion).
- Active contraction of the deltoid muscle if suture allows.
- If there is concern about the fixation or the suture, abduction
on splint until bone union occurs (4-6 weeks).Remove splint
for pendulum exercise only.
- Careful clinical and radiological follow-up.
- If there is any sign of failure of implant or fixation, an abduc-
tion splint is used.
In the upper limb metal implants can be left in place. Only in

the case of inflammatory reaction, or if the implant disturbs the
patient, e. g. impingement with the acromion on movement, es-
pecially abduction, is metal removal undertaken from 12-
18 weeks.
Miiller ME, Allgower M, Schneider R, Willenegger H (1991) Manual of in-

New York
Internal Fixation. Springer. Berlin Heidelberg New York
• 446
7.4 Fractures of the Humeral Shaft
Most low-energy humeral shaft fractures can be treated conser-

vatively and will unite rapidly. Osteosynthesis, however, will be
considered for the following indications:
Open fractures
- Radial nerve damage
- Polytrauma patients
Pathological fractures
Unstable transverse or short oblique fractures
Nonunions or malunions
Unstable transverse or short oblique fractures (relative indi-
cation), especially high-energy fractures.
7.4.1 Anatomy
Humerus from the front (Fig.l a).

Humerus from behind (Fig. 1 b).
Head Head - -?'T'---

Anatomical neck Anatomical neck
Greater tuberosity Greater tuberosity
Lesser tuberosity
-...---,--BiciJ)ital groove Surgical neck
Surgical neck
Shaft
Deltoid tuberosity Radial groove
Deltoid tuberosity
Humerus
Coronoid fossa
Lateral epicondyle
-,__.;:...---- Olecranon fossa
Capitulum Lateral epicondyle - Medial epicondyle
Capitulum ----"'~:Y-....Ai"-/
1a Trochlea 1b Trochlea
o=
~
.c:
..
r:I:J
";
e
Q,l
=
::r:
447
•
7.4.2 Assessment
.d. . 6
- Neuro-vascular damage (radial nerve injury is common). ~30' <30'
- Chest injury.
2
Radiography: AI A2 AJ
- Standard AP view; shoulder and elbow to be seen.
- Lateral view; shoulder and elbow to be seen.
·,
~-
See also Sect. 5.1
3
81 82
Type 12 A: Simple fractures: transverse, spiral, or oblique 83
(Fig. 2).
Type 12 B: One additional fragment: wedge or butterfly
(Fig. 3).
Type 12 C: Complex fractures: spiral, two levels, or multifrag-
mentary (Fig. 4).
7.4.4 Indications for Osteosynthesis-

4
Implants of Choice Cl CJ
C2
Fractures:
- Type A, B and C (Fig. 5).
Implants:
- Broad DCP or LC-DCP, 4.5 mm cortex screws as lag screws.
For small individuals with very slender bone a narrow DCP or
LC- DCP plate can be chosen.
Timing:
- Immediately for fractures of the mid- and distal third of the
humerus, especially with lateral displacement of the distal
fragment (radial nerve at risk). Immediately if radial nerve
function is impaired or disappears during manipulation and
closed reduction.
Position:
- Lateral (or prone) with the arm abducted 90 o on an elbow
support. The shoulder and the elbow are draped free .
• 448
1 Coracoid process
2 Acromion
3 Lesser tubercule
4 Medial epicondyle
5 Axillary nerve
6 Musculo-cutaneous nerve
7 Radial nerve
Incision:
- A posterior incision on a line joining the dorsal margin of the
acromion with the olecranon for fractures of the distal two-
thirds (Fig. 6a). For the upper third, the extended delta-pec-
toral and antero-lateral approach may be chosen (Fig. 6b ).
- Instruments for application of a broad DCP or LC-DCP with
4.5 mm cortex screws as lag screws (p. 112).
Long spiral fractures:

- 4.5 mm cortex screws are inserted first as lag screws (p. 77),
then a broad 4.5 mm DCP or LC-DCP is applied to protect
the lag screw fixation (p. 97). Lag screws may also be placed
6a
through the plate.
1 Acromion Transverse or short oblique fractures :
2 Deltoid muscle (dorsal border)
3 Medial epicondyle of humerus
- These fractures are stabilised with a broad 4.5 mm DCP or
4 Lateral epicondyle of humerus LC- DCP as a compression plate combined, in oblique frac-
5 Olecranon tures, with lag screws (4.5 mm} either separately or in the LC-
6 Axillary nerve
7 Radial nerve
DCP through the plate (p. 100). A broad plate is chosen be-
8 Ulnar nerve cause of its staggered holes. A narrow DCP or LC-DCP with
the holes in line may fissure the bone, since the humeral cor-
tex splinters easily.
Plate length:
- At least a six-hole plate which gives purchase in six cortices in
each fragment. In osteoporotic bone a longer plate is used. In
distal humeral shaft fractures approaching the metaphysis,
two 3.5 mm reconstruction plates extending down the supra-
condylar ridges give good purchase on the short distal frag-
ment.
Plate position:
- In the upper diaphysis the plate is most commonly placed on
the antero-lateral surface of the bone. Fractures of the distal
two-thirds of the humeral shaft should be plated posteriorly.
449
•
The radial nerve is often at risk in fractures at the junction of the

mid- and distal third of the humeral shaft.
Lag screws alone do not give sufficient stability in long spiral
fractures.
The plate can be slipped underneath the radial nerve and the
vessels when applied to the posterior surface of the bone.
The position of the nerve where it crosses the plate in relation to
the screw holes must be noted and documented, in case the plate
should be removed later.
Autologous cancellous bone graft may be used in multifrag-
mentary fractures.
In pathological fractures a combination of a long plate and
methylmethacrylate cement may be the solution.
- To minimise postoperative swelling, the arm may be immo-

bilised on a posterior plaster splint with the elbow in almost
full extension and suspended for 24-48 h.
- Suction drains are removed after 24-36 h.
- Active mobilisation is started on the second or third day.
Only if the plate gives symptoms should it be removed. The

proximity of the radial nerve must be remembered. After plate
removal the patient should abstain from heavy lifting or any
sport for a period of 6-8 weeks.
Mast J, Jakob R, Ganz R (1989) Planning and reduction technique in frac-

New York
• 450
7.5 Fractures of the Distal Humerus
Intra-articular fractures of the distal humerus, both simple and

more complex, as well as open fractures constitute a positive in-
Coronoid fossa
dication for osteosynthesis. Extra-articular fractures are rare in
Lateral epicondyle
adults, but because of a tendency to delayed union, internal fix-
Capitulum
ation may be chosen.
1a Trochlea
7.5.1 Anatomy
Distal humerus from the front (Fig.1a).

Distal humerus from behind (Fig.1 b).
~;......--- Olecranon fossa

Lateral epicondyle - Medial epicondyle
Capitulum --"""'U.........,
lb Trochlea
7.5.2 Assessment
- Vascular and nerve injuries (brachial artery and radial nerve).
- Associated fractures of the humerus shaft, radius and ulna.
~-\ . - Compartment syndrome.
·\- . 1
r~r~-, ~ ~l
})i\·,_ ·._ Radiography:
. ·._
- Standard views with traction and under anaesthesia (in the
.,...
- ,.
- ;. ;-.,
). 1!!-.. i . .
operating theatre if necessary).
·" .l'l .•;
'\ f..\ I ,.. ...... ,..-, - Angiography.
2 I I I I l II ( ~ I\ I
Al A2 - Tomography (multifragmentary fractures).
A3 - AP and lateral radiographs of the normal elbow (can be used
as a template for preoperative planning if reversed).
3 ~I II )II
~~
r-,(-)
I ; II I
See also Sect. 5.1
, I
81 62 63
Type 13 A: Extra-articular fractures (Fig. 2).
IY
~~
L_/t ~ ~L
-v-~ ~~)(~~
Type 13 B: Intra-articular unicondylar fractures (Fig. 3).
Type 13 C: Intra-articular bicondylar fractures (Fig. 4).
.."'=
e
~
=
I
- ..--,
)\ I
\
\
H
11
I
I
'
I I
-,
/
=
-
';
4 ' 1\ I
C2 C3
I
"'
Q
c
451
•
Fracture:
- Displaced fracture of the medial or lateral epicondyle or
condyle (Al, Bl, B2, B3).
Implants: 6
- 4.0 mm cancellous bone screws, 3.5 mm cortex screws, or 4.5
mm cannulated screws as lag screws (Figs. 5, 6).
- One-third tubular plate may be necessary for larger frag-
ments.
Fracture :
- Supracondylar fractures (A2, A3).
Implants:
- 3.5 mm DCP or LC-DCP (Fig. 7) sometimes combined with a
one-third tubular plate.
7
Fracture:
- Multifragmentary intra-articular fractures (Cl-3).
Implants:
- 4.0 mm cancellous bone screws or 4.5 mm cortex screws, if
possible as lag screws, for the reconstruction of the joint, or to
lag other fragments (Fig. 8).
- Defects of the articular surface: 3.5 mm cortex screws as fixa-
tion screw in combination with bone grafting.
9
- 3.5 mm reconstruction plate and a one-third tubular plate
(five to seven holes) or two 3.5 mm reconstruction plates
(Fig. 9).
Timing:
- As soon as possible. Delay more than a few days is associated
with myositis ossificans.
Position:
- Prone (if no vascular lesions) or lateral with arm abducted
90 o on an elbow support. Forearm draped hanging free. Ster-
ile tourniquet.
• 452
Incision:
- Posteriorly from the midline over the distal humerus, curving
radially past and two finger widths from the olecranon to the
posterior border of the ulna (Fig. 10).
- Instruments for insertion of 4.0 mm cancellous bone or 3.5
mm cortex screws (pp. 214, 215).
- Instruments for insertion of 4.5 mm cannulated screws (p.
128).
(p. 216).
216).
(pp. 215, 216).

Medial epicondyle
2 Ulnar nerve
3 Lateral epicondyle Fractures of the medial or lateral epicondyle or condyle (A1,
4 Olecranon B1-3):
5 Radial nerve
6 Deep branch of radial nerve
- Medial or lateral approach.
7 Superficial branch of radial nerve - Identify ulnar nerve in medial approaches.
- Reduction with Kirschner wires, or small hook.
- Lag screw fixation with 4.0 mm cancellous bone screws
(p. 195), 3.5 mm cortex screws (p. 196) or 4.5 mm cannulated
screws (p. 126).
- Application of a one-third tubular plate for larger fragments
(p. 201).
Supracondylar fractures (A2, A3):
Posterior approach (Campbell, van Gorder approach, turn-
ing down tongue of triceps aponeurosis).
- The ulnar nerve is identified.
- Exposure of fracture using Hohmann style retractors medial-
ly and laterally, taking care not to damage the radial nerve on
the lateral side.
- Reduction of the fracture with pointed reduction forceps and
temporary fixation with Kirschner wires.
- Insertion of 3.5 mm cortex screws as lag screws if possible
(p. 196).
- Application of 3.5 mm DCP or LC-DCP as compression or
neutralisation plate (pp. 202, 208) Location of the plate de-
pends on the fracture but most often it is placed on the poste-
rior aspect of the bone. If distal purchase is not adequate in
low fractures two 3.5 mm reconstruction plates (one medially
and one laterally) are used (p. 213).
453
•
Multifragmentary intra-articular fractures (C1-3) see Figs. 8, 9:
- Posterior approach:
- Identify ulnar nerve.
m
- V osteotomy of the olecranon using a fine sharp chisel, frac-
turing, not cutting, the olecranon joint surface (Fig. 11 ).
\t T
- Exposure of the fracture.
- Reconstruction of the joint using Kirschner wires, or 1.6 mm
threaded guide wires if 4.5 mm cannulated screws are to be
used.
t ·;:"
.,
- Insertion of 4.0 mm cancellous bone screw parallel to the

Kirschner wire (p. 195) or insertion of the 4.5 mm cannulated
screw over the threaded guide wire (p. 126).
- If a defect in the joint surface is present a 3.5 mm cortex screw
is inserted as a fixation screw (p. 197). The gap is filled with
cancellous bone graft, carefully impacted so as not to break
loose into the joint cavity.
- A five- to seven-hole 3.5 mm reconstruction plate is con-
toured and fixed to the dorsolateral (radial) side (p. 213).
- On the medial (ulnar) side a one-third tubular plate (p. 200),
also five- to seven-hole, or a 3.5 mm reconstruction plate is
applied on the supracondylar ridge.
- Reattachment of the olecranon using 2 parallel Kirschner
wires and a figure-of-eight tension band wire (p. 366). 12
A 6.5 mm cancellous bone screw in combination with a figure-

of-eight wire may be used for fixation of the olecranon osteoto-
my (Fig. 12). In small ulnae, however, the screw thread may not
pass into the medullary cavity of the shaft and a long 6.5 mm
cancellous screw may jam before it has been driven home.
Contraindications to internal fixation of multifragmentary
supracondylar fractures are advanced age and osteoporosis.
Also, if the trochlea cannot be reconstructed, osteosynthesis is
questionable. Any obstruction by implants of the coronoid or
olecranon fossae must be avoided. Meticulous reconstruction of
the trochlea is mandatory. Where implants transgress the cu-
bital tunnel, the ulnar nerve may have to be transposed anteri-
~ orly: This must be clearly documented and the patient informed
~, lest another surgeon removing a m edial implant in the future
e
f;o,o
damage the nerve in its nonanatomical site.
......"'0=
....~0
=
0
~
~
• 454
- Suction drainage for the first 2-3 days.

- A removable plaster splint is recommended.
- The elbow is extended to 120 o -130 o and suspended in eleva-
tion for24-36 h.
- Active mobilisation without the splint should start at 36--48 h
with the whole arm resting on a smooth horizontal surface.
- Continuous passive motion, if available, is of advantage after
the postoperative swelling has subsided.
Not infrequently the implant has to be removed. The olecranon

wiring often causes symptoms and needs removal after
3-4 months. A plate on the medial supracondylar ridge can be
uncomfortable under the skin and a number of patients ask for
it to be removed. The ulnar nerve is assessed and in case of irri-
tation it is transposed anteriorly at the time of the medial plate
removal.
Heim U, Pfeiffer KM (1988) Internal fixation of small fragments, 3rd edn.

Muller ME, Allgower M, Schneider R, Willenegger H ( 1991) Manual of in-
Muller ME, Nazarian S, Koch P, Schatzker J (1990) The comprehensive
New York
Ruedi T, Hochstetter AHC, Schlumpf R (1984) Surgical Approaches for
"'
=
e""
~
=
=
-;
....
"'
Q
455
•
7.6 Fractures of the Olecranon
Displaced olecranon fractures cause a discontinuity of the ex-

tensor mechanism and disturbance of the joint surface. There is
Olecranon
a strong indication for osteosynthesis.
7.6.1 Anatomy Head
Neck
Left ulna and radius from behind (Fig. 1 a).
Left radius and ulna from the front (Fig. 1 b).
Posterior Posterior
surface surface 1a
Olecranon
Trochlear notch
Radial notch
Coronoid process ---lo(,..---.1 Head
Neck
Tuberosity
1-r--- Bicipital tuberosity
Supinator crest
Shaft
1b
7.6.2 Assessment
- Check active extension of the elbow. If there is proximal
displacement of fragment, the triceps insertion has been
disrupted. AI A2
A3
Radiography:
- APview.
- Lateral X-ray (gives clear view of the olecranon). Watch for
radial head displacement (Monteggia variant).
- Tomography (in multifragmentary fractures or with surface
depression).
61 82 83
7.6.3 AO Classification (Includes Proximal Radius)

See also Sect. 5.1
Type 21 A: Extra-articular fracture (Fig. 2).

Type 21 B: Articular fracture of one bone (Fig. 3).
Type 21 C: Articular fractures of both bones(Fig. 4). (I (2 C3
' 456
-.._
7.6.4 Indications for Osteosynthesis
4
-Implants of Choice
r
,,- ..ic.. ,· .•'
See also Sect. 5.1
r"~·
Fractures:
- Simple transverse or oblique fractures (B1).
Implants:
t - Kirschner wires 1.6 mm and figure-of-eight tension band wire
., 6 1.0 mm or 1.2 mm in diameter.
- 4.0 mm cancellous bone screw as a lag screw first in oblique
fractures (Fig. 5).
Fractures:
- Multifragmentary fractures (Fig. 6).
Implants:
- One-third tubular plate (6-8 holes) (Fig. 7).
- 3.5 mm reconstruction plate.
- 3.5 mmDCPorLC-DCP.
- 4.0 mm cancellous bone screw or 3.5 mm cannulated screw
for lag screw fixation of the coronoid process.(Fig. 8).
7
8
Timing:
- As soon as the skin and general condition of the patient per-
mit.
Position:
- Prone or lateral with the arm abducted 90 o on an elbow sup-
port and hanging free . A sterile tourniquet is applied (Fig. 9)
For simple fractures: Supine with the arm laid across the
chest.
=
Q
=
i:
Col
~
9 0
457 •
Incision:
- Starts in the middle of the supracondylar area of the humerus,
curves radially to avoid the point of olecranon, continuing
distally towards the posterior border of the ulna (Fig. 10).
Preparation of instruments
- Instruments for application of tension band wire (p. 369).
- Instruments for insertion of 4.0 mm cancellous bone screws
(p. 214).
Instruments for insertion of 3.5 mm cannulated screw (p.
134).
216).
(pp. 215, 216).
- Instruments for application of 3.5 mm reconstruction plates
(p. 216). Capitulum of humerus
2 Medial epicondyle
3 Coronoid process
4 Ulnar nerve
5 Median nerve
7.6.6 Checklist for Operative Technique 6 Lateral cutaneous nerve of forearm
7 D eep branch of radial nerve
8 Superficial branch of radial nerve
Transverse or oblique fractures:
- Reduction with a small pointed reduction forceps. A 2.0 mm
drill bit is used to pre-drill the distal transverse hole for the
figure-of-eight wire.
- Insertion of the two parallel Kirschner wires.
- Insertion of the tension band wire deep to the triceps tendon,
around the two Kirschner wires (p. 366).
- In oblique fractures a 4.0 mm cancellous bone screw may be
inserted first as a lag screw (p. 195).
Multifragmentary fractures:
- Reduction first distally and then proceeding towards the joint
using the small pointed forceps and Kirschner wires.
- An associated fracture of the coronoid process is reduced and
fixed with a 4.0 mm cancellous bone screw or a 3.5 mm cannu-
lated screw as a lag screw (pp. 126, 195).
- Insertion of further lag screws where necessary.
- Contouring of the selected plate.
- Protection of the lag screws with a one-third tubular plate,
a 3.5 mm D CP or LC-DCP, or a 3.5 mm reconstruction plate
(pp. 215, 216).
- In fractures proximal to the coronoid process, a tension band
wire may suffice as long as the radial head is normal.
- Bone graft is necessary if there is a bone defect.
• 458
The Kirschner wires must not be crossed but placed parallel.

They should not be angled too anteriorly near the coronoid pro-
cess into the joint.
Before tightening the figure-of-eight wire, two loops should be
made. This allows simultaneous tightening and twisting ensur-
ing uniform tension in the wire. The wire loops are tightened by
pulling, and the slack taken up by twisting. Trying to tighten the
wire by twisting results in an asymmetrical spiral with the dan-
ger of wire breakage (p. 367).
Wires must be straightened first and then pulled and twisted at
the same time to avoid failure.
Tension band wiring can be successfully employed also in osteo-
porotic bone.
- Suction drainage is used for 24-36 h.

- A well-padded posterior plaster splint is used for 2-3 days
with the elbow in medium flexion.
- The arm is elevated so that the elbow is high and the forearm
horizontal on a pillow.
- Active flexion- extension exercises are begun immediately.
- Continuous passive motion is advantageous, if available,
when postoperative swelling has reduced.
Implants should be removed only if they cause symptoms.

Muller ME, All gower M, Schneider R, Willenegger H (1991) Manual of in-
New York
Ruedi T, Hochstetler AHC, Schlumpf R (1984) Surgical Approaches for
0=
=
E
~
Sequin F, Texhammar R (1981) AO/ASIF instrumentation. Springer, ~
Berlin Heidelberg New York 0

459
•
7.7 Fractures of the Radial Head
Displaced radial head fractures may result in loss of motion of

the elbow and forearm rotation. They should be treated opera-
tively, especially in younger patients. Radial head reconstruc-
tion is strongly indicated if there is associated instability of the
humero-ulnar joint complex. A skilled, experienced surgeon is
required for this difficult procedure.
Head
Neck
7.7.1 Anatomy Bicipital tuberosity
1a
Radial head from the front (Fig.1a).
Radial head from behind (Fig. 1 b).
7.7.2 Assessment
1b
- Look for medial bruising to indicate associated humero-ulnar
instability.
- Check for radial nerve function.
Radiography:
- AP and lateral views perpendicular to the radial head.
- Tomography.
7.7.3 AO Classification (Includes Proximal Ulna)
Type 21 A: Extra-articular fractures (see Fig. 7.6.2).

Type 21 B: Articular fractures of one bone (see Fig. 7.6.3).
Type 21 C: Articular fractures of both bones (see Fig. 7.6.4).
7.7.4 Indications for Osteosynthesis

- Implants of Choice
Fractures:
- Wedge fractures and depressed fractures multifragmentary
fractures with intact segment of the radial head still in conti-
nuity with the shaft.
Implants:
- D epending ofthe size of fragment ; 1.5 mm, 2.0 mm or 2. 7 mm
cortex screws as lag screws (Fig. 2) .
• 460
Timing:
- Earliest convenience. Not an emergency.
Position:
- Supine with the arm on an armboard in medium flexion, fore-
arm in pronation.
Incision:
- Dorsolateral longitudinal incision. The exposure is enlarged
with osteotomy of the lateral epicondyle and its reflection an-
teriorly with the extensor muscle origins (Fig. 3).
- Instruments for insertion of 1.5 mm cortex screw as lag screw
(p. 269).
1 Lateral epicondyle
2 Head of radius - Instruments for insertion of 2.0 mm cortex screw as lag screw
3 Olecranon (p. 268).
4 Deep branch of radial nerve - Instruments for insertion of 2. 7 mm cortex screw as lag screw
(p. 267).
- The radial nerve is identified in the substance of the supinator

muscle. Pressure from retractors must be avoided.
- Reduction with fine pointed reduction forceps (termite or
stag beetle reduction forceps).
- Provisional fixation with fine Kirschner wires (0.8 mm or 1.0
mm).
- Insertion of two or more screws as lag screws parallel to the
joint and perpendicular to the fracture planes:
1.5 mm cortex screw (p. 253).
2.0 mm cortex screws (p. 251 ).
2.7 mm cortex screws (p. 249).
- Bone graft is inserted in defect fractures.
If there is no continuity of the head and neck, reduction and fix-

ation is impossible. The head is then excised. Prosthetic replace-
ment is indicated when the elbow is dislocated and the medial
collateral ligament ruptured and/or with associated fracture of
the ulna.
461 •
- Suction drainage is used for 24--36 h.

- A well-padded posterior plaster splint is applied with the el-
bowat900.
- Active flexion- extension and pronation-supination exercis-
es are begun early.
Screw removal is only undertaken if the screw head causes dis-

comfort to the patient.

New York
..="'
-.=
Q,j
CJ
=
"'
·c=
....~
=
-=
=
.~
~
~
• 462
7.8 Fractures of the Radius and the Ulna
Fractures of either one or both bones in the forearm constitute

strong indications for operative stabilisation. It is the only way
of achieving the early mobilisation necessary to ensure recovery
of pronation and supination. Only undisplaced fractures of the
distal third of the ulna may sometimes be treated by non opera-
tive means.
7.8.1 Anatomy
Ulna and radius from the front (Fig. 1 a).

Ulna and radius from behind (Fig. 1 b).
Olecranon Olecranon
Trochlear notch
Radial notch
Coronoid process _ ____;~;-...:;,.) Head
Head
Neck
\--+-- Bicipital tuberosity Neck
Supinator crest
Shaft
Shaft
Interosseous border Interosseous
border
Interosseous Interosseous
border border
Anterior surface
Anterior border Radius Ulna
Head
Head - -...--:J Dorsal tubercle
Styloid process - Styloid process
1a Styloid process 1b Styloid process
7.8.2 Assessment
- Compartment syndrome.
Radiography:
- Standard AP and lateral views.
X -rays also of the distal and proximal ends of both bones.
In ulnar fractures radial head displacement must be checked
(Monteggia injury).
463
•
See also Sect. 5.1
Type 22 A: Simple fractures of one or both bones (Fig. 2)

Type 22 B: Wedge fractures of one or both bones (Fig. 3).
Type 22 C: Complex fractures of one or both bones (Fig. 4).
2
Al A2 A3
Fractures:
- Fractures of the diaphysis.
Implants:
- 3.5 mm cortex screws as lag screws separate or through the
plate.
- 3.5 mm DCP or LC-DCP seven, eight or more holes.
In the proximal or distal end a shorter plate may have to be cho- 3
sen (Figs. 5, 6). 81 82 83
- 4.5 mm DCP or LC-DCP in tall patients.

Timing:
- As soon as possible. Urgently if evidence of compartment
syndrome.
Position: Cl 4
C2 CJ
- Supine.
- Isolated ulnar fractures: arm pronated and laid across the
chest.
- Isolated radial fractures: arm abducted and in neutral rota-
tion.
- Both bones: arm maximally pronated and in abduction, el-
bow flexed.
- Tourniquet.
Incision:
- Ulnar shaft: Parallel and slightly volar to the subcutaneous
crest of the ulna (Fig. 7a).
- Radial shaft: On a line joining the lateral epicondyle of
5
humerus with radial styloid process.(Fig. 7 b) An alternative
is the Henry anterior approach to the radial shaft, through an 6
incision starting at the flexor crease of the elbow and follow-
ing the medial border of the brachioradialis belly distally to-
ward the lower forearm: some surgeons prefer this for more
proximal radial fractures.
Preparation of instruments :
- Instruments for the application of a 3.5 mm DCP or LC-DCP
and 3.5 mm cortex screws as lag screws (pp. 215, 216).
- Instruments for the application of a 4.5 mm DCP or LC-DCP
(p. 112) .
• 464
1 Lateral epicondyle of humerus
2 Olecranon
3 Posterior crest of ulna
4 Styloid process of ulna
1 Lateral epicondyle of humerus

2 Olecranon
3 Styloid process of ulna
4 Styloid process of radius
5 "Mobile wad" (radial extensor muscles
7 Deep branch of radial nerve
7b I 2
7.8.6 Checklist for Operative Technique (Both Bones)
- Approach and atraumatic reduction of the easiest fracture,

usually the ulnar fracture. Both fractures should be exposed
and provisionally reduced before either fixation is complet-
ed.
- The ulnar plate is applied to the medial border of the bone.
- The radial plate is most often placed on the anterior surface in
the upper third and on the dorsolateral side in the distal two
thirds. In distal fractures the flat anterior surface may be the
best site.
- In oblique or wedge fractures 3.5 mm cortex screws are in-
serted as lag screws either separately first or through the
plate.
- Contouring of the plates using the malleable templates.
- Fixation of the plate provisionally to one main fragment with
a screw and to the other side with a small reduction forceps
(or a screw).
- The second bone is approached and its fracture exposed.
- If reduction is impossible the plate on the other bone is loos-
ened and the second bone reduced.
- After reduction and provisional fixation of both bones,
pronation and supination are examined. If free, all the screws
are inserted. The plate is applied either as a compression
plate or as a neutralisation plate (pp. 202- 211).
- Bone graft is applied when a defect or small devitalised frag-
ments are present. The interosseous border must be avoided:
radio-ulnar bridging callus may otherwise form.
- Closure of both incisions without tension may be difficult.
The ulnar wound should preferably be closed, since it is locat-
ed close to the subcutaneous border. The radial wound how-
ever, can be left open over a portion of its length, if the metal
implant is safely placed under the muscle.
465
•
Fractures of the radius with distal radioulnar subluxation

( Galeazzi fracture) (Fig. 8): The subluxation is most often re-
duced by anatomical reduction and stable fixation of the radial
fracture. The stability of the joint must be checked by X-ray.
Fractures of the ulna with associated radial head dislocation
(Monteggia injury) (Fig. 9): In most cases following anatomical
reduction and stable fixation of the ulna, the radial head will re-
duce and remain stable in full supination. An X-ray is taken to
confirm. If reduction is doubtful, the radial head is approached
separately and inspected. Any soft tissue interposition (torn an-
nular ligament or radial nerve) has to be removed and the liga- 8 9
ment repaired. The radial head may now be stable.
If a single fragment of the radial head is present fixation with lag
screws is necessary (see Sect. 7.7.6). In most cases, a long arm
cast in supination is used for 6 weeks.
- Suction drainage is used for the first 24-36 h.

- A well-padded dressing is applied and the arm is kept elevat-
ed for the first 48 h (Fig. 10).
- Fingers, elbow and wrist are moved immediately. Functional
mobilisation starts as soon as there is no pain.
10
Plates in the diaphysis should not be removed earlier than

2 years after fixation. Plates in the proximal radius can be left in
place.
Heim U , Pfeiffer KM (1988) Internal fixation of small fragments , 3rd edn.

MUller ME, All gower M, Schneider R, Willenegger H (1991) Manual of in-
MUller ME, Nazarian S, Koch P, Schatzker J (1990) The comprehensive
New York
RUedi T, Hochstetter AHC, Schlumpf R (1984) Surgical Approaches for
• 466
7.9 Fractures of the Distal Radius
One of the most common fractures, the Calles fracture, is found

in the distal radius region. As a fresh extra-articular fracture it is
most often treated conservatively. Percutaneous Kirschner
wires are sometimes used to maintain reduction. Open reduc-
tion and internal fixation has proved effective for:
- Fractures of the radial styloid, if displaced
- Flexion fractures, e. g. reversed Barton, Smith-Goyrand
- Multifragmentary articular fractures- Y-fractures
7.9.1 Anatomy
~:::~~:ular surface
Styloid process Distal radius from the front (Fig. 1.)
7.9.2 Assessment
- Median nerve function.
Radiography:
- AP and lateral views are essential.
- Tomography for joint fractures.
2
See also Sect. 5.1
A2
Type 23 A: Extra-articular fractures of the radius and/or the

ulna (Fig. 2).
Type 23 B: Partial articular fracture of the radius (Fig. 3).
Type 23 C: Complete articular fracture of the radius (Fig. 4).
3
82
81
~I\I "'
:c=
-
~
I ~
4 -;
Cl C2 C3 s"'
467
•
Fracture:
- Displaced Calles fracture (A2).
Implants:
6
- Kirschner wires (Fig. 5).
Fracture:
- Displaced unstable fracture of the styloid process (Bl).
Implants:
- 4.0 mm cancellous bone screws, 3.5 mm cortex screws or 3.5
mm cannulated screws (Fig. 6).
- 2.7 mm condylar plate.
Fracture:
- Intra-articular fracture with proximal or volar displacement :
reversed Barton (B3).
Implants:
- Small T plate on the volar aspect (Fig. 7).
Fracture:
- Y-fracture (Cl).
Implants:
- Small T plate on the side of greater comminution.
Fracture:
- Multifragmentary articular fracture (C3).
Implants:
- Kirschner wires and small external fixator (Fig. 8).
Small oblique T plate dorsally.
- Cancellous bone graft.
Timing:
- In fresh fractures as soon as possible, especially if evidence of
median nerve compromise. 8
Position:
- Volar approach: Supine with the arm on an arm board ab-
ducted and supinated. The wrist is extended over a roll.
Tourniquet
- Dorsal approach: Supine with the wrist slightly flexed and
placed on an arm board. Tourniquet
• 468
Incision:
- Volar approach: Starts at the thenar crease (linea vitalis)
of the palm, curves toward the middle of the forearm, with a
transverse segment as it crosses the volar flexion crease of the
wrist (Fig. 9).
- Dorsal approach: A z- or s-shaped incision from the base of
the second metacarpal over the wrist to the distal forearm is
suggested for good healthy young skin. The safest incision is a
straight midline longitudinal one in line with the third
metacarpal and into the distal forearm. This passes safely be-
tween the dorsal sensory branches of the ulnar nerve medial-
ly, and of the radial nerve laterally.
- Instruments for application of the small external fixator
(p. 338).
1 Thenar crease ("Linea vitalis'') or 3.5 mm cortex screws (pp. 214, 215).
2 Thenar branch of median nerve - Instruments for insertion of 3.5 mm cannulated screws
3 Median nerve (p. 134).
4 Palmar branch of median nerve
5 Styloid process of ulna - Instruments for application of small oblique or right angle T
6 Styloid process of radius plates (p. 216).
- Instruments for harvesting cortical and cancellous bone
grafts (p. 369).
Fractures of the radial styloid, multifragmentary fresh fractures

and dorsally angulated metaphyseal fractures:
- Dorsal approach.
- Identification of ligaments, tendons,vessels, and the dorsal
branch of the radial nerve.
- Exposure of the fracture using Hohmann-type retractors.
- Reduction with Kirschner wires and/or small reduction for-
ceps.
- Lag screw fixation with 4.0 mm cancellous bone screws
(p. 195) or 3.5 mm cortex screws (p. 196) or 3.5 mm cannulat-
ed screws (p. 133).
- Application of the small oblique or right angle T plate. First
the plate is temporary fixed to the proximal fragment with a
screw in the proximal oval hole. After final reduction and ad-
justing the plate, it is fixed definitively (p. 212).
Fractures with volar and proximal displacement( reversed Bar-
ton fracture):
- Identification of ligaments, tendons, vessels, and the median
nerve for decompression.
- Reduction of volar fragment with small reduction forceps. Y-
fractures are reduced by continuous traction of the thumb.
469
•
- The small T plate is applied first with a screw in the proximal
oval hole and after final reduction the remaining screws are
inserted.
In conjunction with styloid fractures, a scaphoid fracture may

exist as a result of a transscaphoid-perilunar fracture-disloca-
tion. These fractures are fixed with 2. 7 mm cortex screws.
In conjunction with a distal radius fracture a transverse or short
oblique fracture of the distal narrow part of the ulna may occur.
This is an absolute indication for a plate fixation with either a 3.5
mm or a 2.7 mm DCP or LC-DCP.

- A well-padded plaster splint is applied with the wrist slightly
extended in a physiological position.
- The limb is elevated (see Fig. 10 in Sect. 7.8)
- Active mobilisation of the hand and the wrist is started at
24h.
In younger patients and if the implants cause discomfort of any

kind they are removed after consolidation of the fracture
(8 months or more).

New York
• 470
7.10 Fractures in the Hand
Most fractures in the hand are treated conservatively. Open

fractures with severe soft tissue damage may best be treated
with Kirschner wires and cerclage or hemi-cerclage wiring. In
multiple fractures with associated tendon, vascular,and/or
nerve lesions, as well as in fractures involving the articular sur-
face stable, internal fixation is necessary to achieve the best
functional result. Internal fixation of hand fractures should be
made as stable as possible with as little material as possible.
7.10.1 Anatomy
Hand, dorsal view (Fig. l).
Scaphoid - - - - - + -
Trapezium ----:±
Trapezoid ---!"f'+.:::1i;;;;t~--
Metacarpophalangeal - .
joint of thumb
Interphalangeal -
joint of thumb
v Phalanges
Metacarpophalangeal joint
Proximal interphalangeal joint -
Little finger
Distal interphalangeal joint -
Index finger Ring finger

Middle finger
7.10.2 Assessment
- Clinical examination of tendon and neurological function to
the extent that the injury permits.
- Examination also for rotational deformity of the fingers, es-
. pecially in metacarpal fractures.
Radiography:
- AP, lateral and oblique views.
- Good views of the carpus as associated wrist injuries are com-
mon.
The hand and the carpal bones are in the anatomical zone 7. The
subtypes and groups are not yet defined.
471
•
7.10.4 Indication for Osteosynthesis-
Implants of Choice
Fracture:
- Displaced, unstable scaphoid fracture, especially with lunate
displacement.
3
Implants:
- 2.0 mm or 2.7 mm cortex screws as lag screws (Fig. 2).
- 3.5 mm cannulated screws as lag screws.
Fracture:
- Extra-and intra-articular fractures of the first metacarpal,
e. g.Bennet's and Rolando's fractures.
Implants: 4
- Threaded or non threaded Kirschner wires (small-sized frag-
ments).
- 2.0 mm or 2.7 mm cortex screws as lag screws (Fig. 3; Ben-
net's fracture).
- 2.7 mm Tor L plates (Fig. 4. Rolando's fracture).
- 2.0 mm condylar plate.
Fractures:
- Unstable, displaced fractures of the second to fifth
metacarpals.
Implants:
- Percutaneous pinning with Kirschner wires 1.6 mm or 2.0 mm
diameter in small fragments. Transosseous sutures (Fig. 5).
- 2.0 mm T plate or condylar plate in displaced basal fractures
of second and fifth metacarpals (Fig. 6).
- Small external fixator in multifragmentary fractures.
- 2.0 mm or 2.7 mm cortex screws as lag screws in spiral frac- 6
tures (see Fig. 7).
- Quarter-tubular plate or 2.7 mm DCP as neutralisation plate,
especially in lag screw fixation of the second to fifth
metacarpals, particularly spiral fractures with rotational dis-
placement (see Fig. 7).
• 472
Fracture:
- Articular fractures of the proximal interphalangeal (PIP)
joints and the distal interphalangeal (DIP) joints.
- Phalangeal shaft fractures prone to secondary angular defor-
mation in normal rotation.
Implants:
- Kirschner wires 1.0 mm or 1.25 mm in diameter.
- 1.5 mm or 2.0 mm cortex screws as lag screws (see Fig. 7 ).
- 1.5 mmor2.0 mmcondylarplates (see Fig. 7).
Timing:
- As soon as possible in fresh fractures.
Position:
- Supine with the hand on a radiolucent armrest.
Incision:
- First metacarpal: dorso-ulnar or dorso-radial approach (Fig.
Sa).
- Second to fifth metacarpals: longitudinal between the bones
and withY-extensions as necessary.
- Phalanges: longitudinal dorsolateral (Fig. 8 b).
- Instruments for insertion of Kirschner wires (p. 234 ).
- Instruments for insertion of 1.5 mm or 2.0 mm cortex screws
and mini-condylar plates (pp. 268, 269).
- Instrumentsforinsertionof2.7 mmcortexscrewsand2.7 mm
plates (p. 267).
- Instruments for insertion of 3.5 mm cannulated screws
(p. 134).
- Instruments for application of the small external fixator
(p. 338).
Scaphoid fractures:
- The superficial branch of the radial nerve is identified and re-
tracted dorsally.
- The tendons and the radial artery retracted; direction de-
pends on exact choice of surgical approach.
- The fracture is exposed and reduced with atraumatic eleva-
tors, fine forceps or small hook.
- A Kirschner wire, threaded or nonthreaded, is inserted from
the tubercle across the fracture site.
473
•
- The length is determined.
- The 2.0 mm or the 2.7 mm cortex screws (pp. 249, 251), or
the 3.5 mm cannulated screws are inserted as a lag screws
(p. 133).
Fractures of the first metacarpal:
- Nerves and tendons are identified.
- The fracture is temporary reduced with fine Kirschner wires
or fine reduction forceps.
- Lag screw fixation from the dorsal side with 2.7 mm or 2.0
mm cortex screws (pp. 249, 251).
- In intra-or extra articular fractures, a 2.7 mm T plate is ap-
plied after restoration of the articular surface with Kirschner
wires (p. 259). A 2.0 mm condylar plate is an alternative
(p. 264).
Fractures of the second to fifth metacarpals:
- Long spiral fractures of the shaft are fixed with 2.0 mm or 1.5
mm cortex screws as lag screws, sometimes combined with a
2.0 mm DCP as protection plate (p. 265).
- Transverse fractures of the shaft may be fixed with 2.0 mm
DCP or H-plate (p. 266).
- Distal transverse fractures are fixed with a dorsal 2.7 mm or
2.0 mm T plate.
- Oblique fractures close to the joint are fixed with a lateral2.0
mm or 1.5 mm mini-condylar plate.
- Basal, unstable fractures are fixed with a dorsal 2.0 mm T
plate or2.0 mm condylar plate (p. 264).
Articular phalangeal fractures:
- Condylar fractures are in general fixed with mini lag screws or
mini-condylar plates. Devascularisation must be avoided.
Large dorsal fragments and volar avulsion fractures:
- These fractures may be fixed with minilag screws. Comminu-
tion of the fragment is quite common.
Multifragmentary fractures:
- Secondary arthrodesis is suggested, especially if the soft tis-
sue condition is poor. Screw fixation (2.0 mm) in combination
with corticocancellous grafting is recommended for large
bony defects.
Fractures of the phalangeal shaft:
- Displaced shaft fractures of the middle phalanx may be best
fixed with a laterally placed 1.5 mm straight plate or a 1.5 mm
condylar plate (p. 266).
- Plating is rarely indicated, but may be advantageous in com-
bination injuries and transverse fractures.
- Percutaneous Kirschner wires are used as intramedullary
splints for basal transverse fractures and certain spiral frac-
tures. The wires are inserted across the joint of the middle
phalanx (MP) .
• 474
Temporary transarticular Kirschner wires across the PIP and

DIP joints may be necessary if there is a danger thatthe fixation is
not rigid enough or that fragments tend to dislocate in extension.
Fixation with Kirschner wires is still the commonest method in
phalangeal fractures despite the tendency for distraction to oc-
cur. Care must be taken to avoid concomitant fixation of neigh-
bouringjoints.

- Internal fixation of hand fractures is supplemented by a care-
fully shaped external plaster splint for 4-6 weeks, with judi-
cious removal for carefully supervised active movements
from an early stage.
- Elevation ofthe arm. See Fig. 10 in Sect. 7.8.
Kirschner wires and external fix a tors are removed after fracture
healing (4-6 weeks). Other implants are removed on request
after 8-12 months.

MUller ME, Allgower M, Schneider R, Willenegger H (1991) Manual of in-
MUller ME, Nazarian S, Koch P, Schatzker J (1990) The comprehensive
New York
RUedi T, Hochstetler AHC, Schlumpf R (1984) Surgical Approaches for
475 •
7.11 Fractures of the Pelvis
Fractures of the pelvis have become a focus of increasing interest

in recent years and numerous studies have been done with re-
gard to different types of injury, treatment, and late results.
These studies have shown that approximately 65% of pelvic
fractures are stable injuries, rarely requiring internal fixation.
Unstable pelvic injuries may have rotational instability or linear
instability. Rotationally unstable injuries are mostly of the
"open book" type and become stable if closed. External fixation
may well achieve this. In linear instability, the sacroiliac complex
is totally disrupted and the hemipelvis migrates proximally and
posteriorly. In this instance, internal fixation is usually required.
The polytraumatised patient with a disruption of the pelvic ring
has a very serious injury which carries a high mortality.
The essential management of polytrauma should include the
stabilisation of musculo-skeletal injuries as early as possible.
Sometimes the immediate stabilisation of the pelvis with a
pelvic C-clamp, or an external fixator, may be lifesaving and the
definitive stabilisation undertaken only when the patient's con-
dition allows.
7.11.1 Anatomy
Male pelvis, from above and in front (Fig.l a).

Lateral (external) surface of the right pelvis from the front
(Fig.l b).
Lateral (external) surface of the pelvis from behind (Fig.l c).
The pelvis is a ring structure. Its function is:

1. To transmit forces from the legs to the spine, and
2. To protect vital organs and major blood vessels within its cav-
ity.
Pelvis
Body of first sacral vertebra Ala
Promontory
Margin of acetabulum
Pubic tubercle --'~"'-~"'-
1a
• 476
Pelvis
Posterior gluteal line

Posterior iliac spine Anterior superior
iliac spine
Greater sciatic notch -----J

Rim of acetabulum
Acetabulum
Ischial spine
Lesser sciatic notch
Ischium
Ischial tuberosity
Posterior superior iliac spine
Pelvis
lb Acetabular notch
Iliac crest
Greater sciatic notch
Rim of acetabulum Anterior superior

- iliac spine
Ischial spine
A""'~~'l----- Anterior inferior
iliac spine
lc
7.11.2 Assessment
Mechanism of injury. Skin damage gives a clue to the likeli-
hood of major injury, e. g. tyre marks on lower abdomen.
General assessment of the polytraumatised patient (airway,
bleeding, CNS).
The lower urinary tract (urethra or bladder) may be injured -
assessment by an appropriate surgeon should be made before
catheterisation.
Inspection for major bleeding, or wounding in the ano-genital
area.
477
•
- Careful peripheral neurological examination of the lower
limbs.
- Determination of pelvic stability.
Radiography :
- AP view in the acute phase
- Inlet view; X-ray beam directed 60 o from the head to the mid-
pelvis (posterior displacement).
- Outlet view; X-ray beam directed 45 ° from the foot to the
symphysis (vertical migration of the hemipelvis ).
- CTscan
7.11.3 AO Classification (Tile)
Type A: Stable, minimally displaced. Pelvic ring is intact or not

displaced (Fig. 2).
Type B: Rotationally unstable, vertically stable, including
"open book" injury, lateral compression injury
(Fig. 3).
Type C: Rotationally and vertically unstable, vertical shear.
Rupture of the entire pelvic floor, including the
sacroiliac complex (Fig. 4).

Implants of Choice
Fracture:
- Open book fracture, more than 2.5 em (Type B 1) without
posterior instability.
Implants:
- External fixation, anteriorly
- Two-or three-hole 4.5 mm DCP, LC-DCP or reconstruction
plate, on the superior aspect pelvis symphysis. Two plates in
large patients (Fig. 5).
Fracture:
- Open book injury as part of a vertically unstable type C injury. 5
Implants:
- Two- or three-hole 4.5 mm DCP, LC-DCP, or reconstruction
plate superiorly, and 3.5 mm (or 4.5 mm) reconstruction plate
anteriorly (Fig. 6).
Fracture :
- Sacroiliac dislocation or fracture dislocation .
• 478
Implants:
- Two- or three-hole 3.5 mm DCP, placed across the anterior
aspect of the sacroiliac joint. Usually two plates side to side
(Fig. 7).
- 7.0 mm cannulated screws or 6.5 mm cancellous bone screws
as lag screws inserted from the posterior aspect into sacrum
with image intensification control in two planes (according to
Matta) (Fig. 8).
/
/'<""'<
' / '\
8
Fracture:
- Iliac fractures.
Implant:
- 7.0 mm cannulated screws or 6.5 mm cancellous bone screws
as lag screws (Fig. 9).
- 3.5 mm or 4.5 mm DCP or reconstruction plates (Fig. 10).
Fracture:
- Sacral fracture, vertically unstable.
Implant :
- Sacral bars1 (Fig. 11).
- 7.0 mm cannulated screws, especially in non unions.
Timing:
- Early pelvic stabilisation with the pelvic C-clamp or with a
simple anterior external frame is performed in patients with
wide open book injury or unstable pelvic fractures. This re-
duces the intrapelvic venous and bony bleeding.
1 Sacral bars in lengths from 100 mm to 200 mm in 20 mm increments are
presently being developed. Contact SYNTHES for information.
479
•
- Definitive fixation is performed when the patient's general
state has improved, usually after 5-7 days.
Positioning:
- Ruptures of the symphysis pubis: Supine with both anterior
superior iliac spines freely accessible.
- Posterior fixation of the sacroiliac joint or the gluteal aspect
of the ilium: Lateral or prone so that the entire wing of the ili-
um freely accessible. 7
- Anterior sacroiliac fixation: Supine with roll or pad beneath
buttock, the whole wing of ilium accessible for ilio-inguinal 3
approach.
Incision:
- Ruptures of the symphysis pubis: Horizontal incision about
\ 12
1 Anterior superior iliac spine

15-20 em one to two finger widths above the symphysis
2 Symphysis pubis
(Fig. 12). 3 Greater trochanter
- Posterior fixation of the sacroiliac joint or the gluteal aspect 4 Ilio-hypogastric nerve
of the ilium: Starts one to two finger widths distally and later- 5 Ilio-inguinal nerve
6 Lateral cutaneous branch
ally to the posterior superior iliac spine, extends upward par- of ilio-hypogastric nerve
allel to the iliac crest, and terminates two to three finger 7 Lateral cutaneous nerve of thigh
widths past the highest point of the crest. The superior clunial
nerves must be divided (Fig. 13).
- Anterior sacroiliac fixations: Incision starts at mid-inguinal
point and follows the anterior 3/4 of iliac crest backwards
(Fig. 14). 8
Preparation of instruments :
- Instruments for application of external fixation (p. 321 ).
(p. 112).
- Instruments for application of 4.5 mm reconstruction plates
(p. 112). 2- <-/-il-l!E-
- Instruments for application of 3.5 mm reconstruction plates 6 ->-1-------Jr;~,..;Jf

(p. 216).
- Instruments for inserting of 7.0 mm cannulated screws
(p.121).
4
Unstable injuries of the pelvic girdle:

13
- Acute stabilisation with the pelvic C-clamp (p. 222).
1 "Supracristal point"
"Open book" injuries - external fixation: (highest point of iliac crest)
- Application of a simple anterior rectangular frame. Two pins 2 Posterior superior iliac spine
3 Medial sacral crest
are placed percutaneously in each ilium at approximately 45 o 4 Greater trochanter
to each other, one in the anterior superior spine and one in the 5 Inferior gluteal nerve
iliac tubercle, and joined by an anterior rectangular configu- 6 Superior gluteal nerve
7 Lateral cutaneous branch
ration. of ilio-hypogastric nerve
8 Superior clunial nerves
• 480
"Open book" injuries- plate fixation:
- Exposure of the obturator foramen and application of the
pelvic reduction forceps through the foramen.
- Anatomical reduction. Care must be taken to avoid trapping
the bladder or the urethra in the symphysis when closing the
clamp.
- Application of a two-or three-hole DCP or LC-DCP fixed
with fully threaded 6.5 mm cancellous bone screws on the su-
perior aspect of the symphysis pubis (p. 94 ).
- In unstable pelvic disruption, application of an additional 3.5
mm reconstruction plate on the anterior aspect to avoid dis-
placement in the vertical plane (p. 213).
14 Sacroiliac dislocation or fractures of the ilium, anterior ilio-in-
1 Anterior superior iliac spine guinal approach:
2 Symphysis pubis - Exposure of the iliac crest and the sacroiliac joint including
3 Greater trochanter
the ala of the sacrum.
4 Ilio-hypogastric nerve
5 Ilio-inguinal nerve - Anatomical reduction with pointed reduction forceps in the
6 Lateral cutaneous branch anterior superior spine of the ilium pulling forwards. The re-
of ilio-hypogastric nerve
duction is checked anteriorly at the greater sciatic notch.
7 Lateral cutaneous nerve of thigh
Care must be taken not to damage any nerves, especially the
L5 root in front of the sacroiliac (SI) joint.
- Application of two two- or three-hole 3.5 mm DCP or LC-
DCP (p. 202) fixed across the anterior surface of the sacroili-
ac joint with 4.0 mm fully threaded cancellous bone screws.
Only one screw can be inserted into the sacrum to avoid the
L5 nerve root, and only one or two into the adjacent ilium
since the bone rapidly becomes very thin.
- In iliac fractures lag screw fixation with 7.0 mm cannulated
screws (p. 117), or 6.5 mm cancellous bone screw (p. 81) may
suffice or be complemented with a plate near the iliac crest.
Sacroiliac dislocation or fracture dislocation, posterior ap-
proach
- Exposure of the posterior superior spine, iliac crest and the
sciatic notch. (Beware of the sciatic nerve.)
- Anatomical reduction, checked by placing the finger through
the sciatic notch exploring the anterior aspect of the sacrum.
- A guide wire is inserted in the ala of the sacrum, across into
the body of S1 and its position verified with image intensifica-
tion.
- Insertion of one or two 7.0 mm cannulated screws with cau-
tion. Penetration of the neural canal or the S1 foramen is a se-
rious complication. Image intensification is essential. The
second screw is inserted distally to the S1 foramen where,
however, the bone is extremely thin. Percutaneous insertion
of the cannulated screws is possible in the most experienced
hands.
481 •
Sacral fractures, posterior approach
- Exposure of the posterior spine
- A gliding hole is made through the posterior superior spine
and a threaded bar driven through until it hits the opposite
posterior iliac spine and emerges on the outer table of the iliac
crest. Washers and nuts are applied and tightened and the bar
cut off flush at the nut (Fig.15).
- A second bar is placed distally and parallel to the first. The 15a
bars must be placed posterior to the sacrum to avoid the
sacral spinal canal. The anterior sacral foramina may be pal-
pated by placing a finger through the greater sciatic notch to
the anterior surface of the sacrum and the posterior foramina
may be visualised directly.
The posterior approach may be considered safe and straightfor-

ward, but there is a great risk of wound breakdown and nerve
damage. Traction is used temporarily before surgery and often
as postoperative care. Pelvic fractures may be associated with
fractures of the acetabulum (See Sect. 7.12).
- Extensive multiple drainage for 24--48 h.

- The postoperative care is dependent on the quality of the fix-
ation and the bone.
- If stability is secure both anteriorly and posteriorly, early mo-
bilisation on crutches may start.
- To avoid asymmetrical load on the healing pelvis, swing-
through (mermaid) walking with two crutches is advisable.
Implants may be left in. Only in case of complaints are implants

removed after 10 months. This usually applies only to sacral
bars and screws in the iliac crest.
MUller ME, All gower M, Schneider R, Willenegger H (1991) Manual of in-

• 482
7.12 Fractures ofthe Acetabulum
Acetabular fractures are joint fractures and as such they require

exact anatomical reduction to ensure a good long-term function
of the hip joint. Closed reduction may be possible in a few cases,
but more often open reduction and stable internal fixation are
required. A satisfactory result may only be expected if the joint
is congruous and stable following reduction, and if complica-
tions are avoided. This surgery is extremely demanding. It re-
quires a skilful, experienced team and the best material re-
sources. The age and the general state of the patient, as well as
the assessment of other major injuries in the polytraumatised
will determine the treatment. Traction may be the best option in
elderly patients with poor bone quality.
Late complications such as avascular necrosis of the femoral
head, heterotopic ossification, chondrolysis, and sciatic or
femoral nerve injury may jeopardise the result.
7.12.1 Anatomy
Lateral (external) surface of the right pelvis from the front

(see Fig. 1 b, p. 477).
Lateral (external) surface of the pelvis from behind (see Fig.l c,
p. 477).
7.12.2 Assessment
- Detailed respiratory and hemodynamic appraisal in poly-
trauma.
- Monitoring of pulse, blood pressure, and urinary output.
- Urological and neurological injuries.
Radiography:
- APview.
- A 45 o oblique view of the pelvis with the hip rotated toward
the X-ray tube (the obturator oblique).
- A 45 o oblique view of the pelvis with the hip rotated away
from the X-ray tube (the iliac oblique).
- CT scan of the pelvis.
483 •
Type A: Only one column of the acetabulum involved; posteri-

or wall, posterior column, anterior wall fracture and
variations (Fig. 1).
Type B: Transverse fracture component, where a portion of
the roof remains attached to the intact ilium. (Fig. 2).
Type C: Fractures in both columns; fractures involving the an-
terior as well as the posterior column. All articular seg-
ments, including the roof, are detached from the re-
maining posterior segment of the intact ilium. (Fig. 3 ).
A1.1 A2.2 A3.1 A3.2
2 2 91.2 913
C3.2
3 C 1.2 C2 3
~
..."'
....=
~
~
...
l;oo
"'=
0
·c
....~
0
.:....=
~
~
~
• 484
Implants of Choice
Fracture:
- Posterior wall fracture (type A) (Fig. 4).
Implants:
- 6.5 mm cancellous bone screws as lag screws.
- 4.0 mm cancellous bone screws.
- 3.5 mm reconstruction plate, curved.
Fracture:
- Anterior column and hemitransverse fractures (type B)
(Figs. 5, 6).
Implants:
- 7.0 mm cannulated screws.
- 3.5 mm reconstruction plate, straight.
Fracture:
- Fractures of both columns (type C) (Fig. 7).
Implants:
- 3.5 mm cortex screws, extra long.
- 3.5 mm reconstruction plate, curved.
Timing:
- Surgery is usually delayed until local bleeding has subsided
and the patient is fit. Ideally it is performed within 10
days.Vascular or nerve injuries are indications for immediate
surgery. Irreducible or unstable posterior dislocation of the
femoral head is an indication for urgent surgery.
Positions:
- For the Kocher-Langenbeck approach (fractures type Al,
A2, Bl ): Lateral or prone on a fracture table or a regular table
on a vacuum mattress. The leg is draped to be freely mobile.
The draping leaves most of the buttock free.
- For the straight lateral and ilio-femoral approach (fracture
types A2, A3, Bl, B2, C2, C3): Lateral on a fracture table or
on regular table on a vacuum mattress The leg is draped freely
mobile. The area is draped free to the symphysis pubis, to the
485
•
rear portion of the buttock, the costal margin and to the mid- 2 3
thigh.
- For the ilio-inguinal approach (fractures type A3, B3, Cl):
Supine on a fracture table or a regular table on a vacuum mat-
tress. The leg is draped freely mobile.
Incisions:
- Kocher-Langenbeck or posterior approach for fracture types
Al, A2, Bl: The knee must be flexed at all times to relax the
sciatic nerve (Fig. 8).
- The straight lateral approach for fracture types A2, B1, B2,
C2: Knee kept flexed (Fig. 9).
- The extended ilio-femoral incision for fracture types Bl.2,
B1.3, Cl.2, C2, C3 (see above).
- The ilio-inguinal approach for fracture types A3, B3, C1 (see
Fig.14, p. 480).
- Pelvic reduction instruments (seep. 220). 1 Anterior superior iliac spine
2 "Supracristal'"point
- Instruments for application of the femoral distractor (see (highest point of iliac crest)
p. 352). 3 Posterior superior iliac spine
- Instruments for application of 6.5 mm cancellous bone 4 Greater trochanter
5 Sciatic nerve
screws (p. 82). 6 Superior gluteal nerve
- Instruments for application of 7.0 mm cannulated screws
(p.121).
- Instruments for application of 4.0 mm cancellous bone 3 I
screws (p. 214). \I
(p. 216).
7.12.6 CheckJist for Operative Technique
The complexity of acetabular fractures does not allow for a de-

scription of a step by step procedure, but only general guide-
lines, which concern all fracture types:
- Reduction of a dislocated sacroiliac joint or displaced sacrum
first.
- Anatomical reduction of single articular fragments using the
special pelvic reduction forceps assisted by distraction with
femoral distractor.
- Fixation with 6.5 mm cancellous bone screws as lag screws
(seep. 81).
- Fixation with 7.0 mm cannulated screws as lag screws (see
p.117).
- Reduction and fixation of all extra-articular fragments. 1 "Supercristal point"
(highest point of iliac crest)
- Assessment of the accuracy of reduction by direct vision and 2 Gluteal tuberosity
by checking the cortex of the innominate bone. 3 Anterior superior iliac spine
- The articular surface must be visualised by a wide caps uloto- 4 Posterio r superior iliac spine
5 Greater trochanter
my. A "corkscrew" in the femoral neck allows better retrac- 6 Sciatic nerve
tion of the femoral head and visualisation of the articular sur- 7 Superior gluteal nerve
face, if no distractor is available. The corkscrew should be in-
serted deep into the femoral neck to avoid damage to the
blood vessels supplying the head.
- Application of 3.5 mm reconstruction plate with fully thread-
ed 4.0 mm cancellous bone screws to buttress the lag screw
fixation (pp. 195, 213).
Heterotopic ossification is a major complication of the ilio-

femoral and posterior approaches. Plates are applied to the an-
terior column from the inner table of the ilium, to the symphysis,
the posterior column and the superior aspect of the acetabulum.
When plating the posterior column, the distal screw should be
anchored in the ischial tuberosity. Screws in the central portion
must not penetrate the articular cartilage of the acetabulum.
Plates must be meticulously contoured to the column before ap-
plication. Displacement of the opposite column may otherwise
occur.

- Passive mobilisation of the hip may be started within a few
days. If reduction and internal fixation has been successful,
gait training with active hip mobilisation may be started, usu-
ally 5-10 days after surgery.
- Partial weight-bearing (15 kg) on the affected extremity is al-
lowed. Full weight-bearing can normally be started 8 weeks
after internal fixation.
- If rigidity of the fixation is in doubt, a period of 4 weeks in
skeletal traction with free movement in bed is sometimes
used.
Implants may be left in. Only in case of complaints are implants

removed after 10 months.
MUller ME, Allgower M, Schneider R, Willenegger H (1991) Manual of

internal fixation, 3rd edn. Springer, Berlin Heidelberg New York
Riiedi T, Hochstetler AHC, Schlumpf R (1984) Surgical Approaches for
Schatzker J. Tile M (1987) The rationale of operative fracture care.
487
•
7.13 Fractures of the Proximal Femur
Fractures of the proximal femur can be divided into head frac-

tures, neck fractures, and trochanteric fractures . Sub-
trochanteric fractures with an extension into the trochanteric
area are also discussed in this part.
Femoral head fractures are always part of a combined injury to
the hip joint. Shear fractures, often with depression of the
femoral head, are treated with internal fixation, if the blood
supply is intact. Shear fractures combined with femoral neck
fractures are best treated with either arthrodesis or joint re-
placement.
Femoral neck fractures are intra-articular. Depending on the lo-
cation of the fracture the blood supply can be damaged, leading
to avascular necrosis (especially displaced subcapital fractures).
In the elderly, impacted subcapital neck fractures do not require
internal fixation. In younger patients, however, internal fixation
with screws is considered. To prevent impairment of the blood
supply to the femoral head, evacuation of the haemarthrosis is
recommended, also in the elderly. Transcervical neck fractures
are unstable and require internal fixation. They have a high rate Greater trochanter Fovea of head
of avascular necrosis. Pressure of the haemarthrosis may influ-
ence the blood supply to the head, and surgery is therefore ad-
vocated within 6 h.
Trochanteric fractures are almost always extra-articular, and Head
therefore not associated with the danger of avascular necrosis.
Neck
This is the most frequent fracture of the proximal femur, mostly
found in the older age group. Today, internal fixation is accept- Lesser trochanter
ed as the method of treatment. Subtrochanteric fractures pre- Intertrochanteric line
sent a challenge to the operating team in that anatomical reduc-
tion and internal fixation is difficult. Nevertheless, this is
considered the treatment of choice. See also Sect. 4.2.
Shaft
1a
7.13.1 Anatomy
Greater trochanter
Proximal end of the right femur from the front (Fig.l a).
Fovea of head
Proximal end of the right femur from behind (Fig.l b).
Head -~,.--
Piriform fossa ---'r~~-..::....J
Neck - - - - . ; -
Quadrate tubercle
1b
• 488
7.13.2 Assessment
- In the elderly, careful geriatric medical assessment is essential
before a management decision can be made.
Radiography:
- Standard X-ray, also of the uninjured side.
- AP X-ray to check congruency of femoral head and acetabu-
lum.
- Lateral X-ray (cross-table lateral) to check retroversion of
the femoral head in neck fractures.
- Magnetic resonance imaging (MRI) or scintigraphy have
been suggested to check vascularity of the femoral head in
neck fractures
- Computed tomography may be used to visualise anterior and
posterior depressions or shear fractures of the femoral head.
- Tomography, occasionally useful in doubtful neck fractures.
2 AI A2 A3
3 81 B2 83
See also Sect. 5.1
Type 31 A: Trochanteric area (Fig. 2).

Type 31 B: Neck fracture (Fig. 3).
4 Cl C2 C3 Type 31 C: Head fracture (Fig. 4).

Implants of Choice
Fracture:
- Large shear fragment of the head in young patients (C3.1).
489
•
Implants:
- 4.0 mm cancellous bone screws as lag screws (Fig. 5).
Fracture:
- Shear fracture of the head combined with neck fracture
(C3.2, C3.3).
Implants:
- Total hip replacement (THR) or arthrodesis with cobra head
plate depending on age (Fig. 6).
Fracture:
- Femoral neck fractures (B2, B3).
Implants:
- Three 7.0 mm cannulated screws, or 6.5 mm cancellous bone
screws (Fig. 7).
- 130 o angled blade plate (Fig. 8).
- DHS, with separate 6.5 mm cancellous bone screws (Fig. 9).
Fracture :
- Trochanteric- or intertrochanteric fractures.
Implants:
- DHS, in old patients with osteoporotic bone for unstable
fractures with smaller fragments (Fig. 10).
- 95 o condylar plate, especially in younger patients with large
fragment fracture-and good quality bone ( A1) (Fig. 11 ).
- DCS in younger patients (A3) (Fig. 12).
Fracture :
- Subtrochanteric fracture with extension into the trochanteric 7
area.
Implants:
- 95 ° condylar plate (Fig. 13).
- DCS.
10
· 11 12
13
• 490
Timing:
- Open reduction and internal fixation should be performed as
an urgent procedure within 6 h because of the risk of damage
to the vascular supply of the femoral head.
- Joint replacements are elective procedures, but a displaced
femoral head must be repositioned as an emergency manoeu-
vre prior to any further diagnostic steps.
Positioning:
- Supine with some padding beneath the buttock; the leg is
draped so that it can be freely moved. A fracture table is often
used to allow easy X-ray control.
Incision:
- A straight incision along a line joining the greater trochanter
to a point approximately a handbreadth below the fracture
(Fig. 14).
(p. 214).
- Instruments for insertion of 7.0 mm cannulated screw
(p.121).
1 Anterior superior iliac spine
- Instruments of insertion ofDHS (p. 150).
2 Greater trochanter - Instruments for insertion of DCS (p. 150).
- Instruments for insertion of 95 o condylar plate (p. 172).
Large shear fractures of the femoral head:

- By drilling 2 mm holes in the main fragment, bleeding will
confirm the preservation of the vascular supply.
- Anatomical reduction using for example a small sharp hook.
(p. 195).
- Elevation of a depression and bone grafting.
Femoral neck fracture :
- Anterior caps ulotomy in line with the neck.
- Removal of the intracapsular haematoma.
- The fracture is exposed with the aid of three retractors;
one long-tip 16 mm retractor and two short-tipped retrac-
tors. The head can be stabilised with the tip of an 8 mm re-
tractor.
- Fixation with 7.0 mm cannulated screws (p. 117) or 6.5 mm
cancellous bone screw (p. 81).
- Fixation with DHS and additional 6.5 mm cancellous bone
screws as lag screws to prevent rotation of the head ( p. 143).
491
•
Trochanteric fractures:
- Closed reduction is attempted; light traction, external rota-
tion and abduction, otherwise open reduction and stabilisa-
tion with one ofthe following:
- Fixation withDHS (p. 143).
- Fixation with DCS (p. 150).
- Fixation with 95" condylar plate used with tension device
(p. 161).
Subtrochanteric fractures with extension into the trochanteric
area:
- Exposure of the fracture.
- Reduction of type A and B fractures before introduction of
the condylar plate.
- In multifragmentary fractures (type C): introduction of the
condylar blade plate before reduction using indirect reduc-
tion technique with the distractor ( p. 355).
- Cancellous bone graft may be inserted in multifragmentary
fractures.
Stable impacted subcapital fractures in older patients do notre-

quire internal fixation, unless they dis impact. Evacuation of the
haemarthrosis may still be recommended to prevent impair-
ment of the blood supply to the femoral head.
In femoral neck fractures with a vertical fracture plane the
shearing force can be transformed into compression force by an
intertrochanteric valgus osteotomy of 30 o - 40 o.
Preoperative drawings and planning of internal fixation for sub-
trochanteric fractures may help achieve a good result. A re-
versed X-ray of the normal side is used as a model.
If a 95 o condylar blade plate or a DCS is used for the fixation of
subtrochanteric fractures, the placement of the window for the
seating chisel is of great importance. It is prepared at the junc-
tion of the anterior and the middle thirds of the greater
trochanter. The seating chisel is inserted into the neck 1 em be-
low its superior cortex.
The condylar plate is introduced and fixed with a cortex screw in
the proximal fragment into the calcar. The plate is then lined up
with the shaft and a self-centring bone-holding forceps applied.
The distractor is then applied with one bolt through the second
plate hole and the other in a predrilled 4.5 mm hole distal to the
plate. Slight distraction will enable reduction of the fragments
and fixation of the plate first distally, then any lag screws and fi-
nally the remaining plate screws. Intraoperative X-ray control is
a wise precaution. See also p.18 .
• 492

- Postoperative AP and cross-table lateral X-ray views.
- The entire leg is placed in a neutral position in a rubber foam
splint.
- Mobilisation in a frame or with crutches on the 1st postopera-
tive day.
- Depending on the stability, partial weight-bearing is allowed.
In the elderly this may not be advisable.
- Isometric muscle exercises as soon as possible.
- Proximal femur fractures normally take 3-5 months to heal.
In young patients implants may be removed after 12-18 months

if healing has been uneventful. In the elderly implants are gen-
erally left in place if not symptomatic.

AO classification of fractures oflong bones. Springer, Berlin Heidelberg
New York
Regazzoni P, Riiedi T, Winquist R, Allgower M (1985) The dynamic hip
screw implant system. Springer, Berlin Heidelberg New York
...
e=
~
r.
=e
·~
...Q
=-
493
•
7.14 Fractures of the Femoral Shaft
Femoral shaft fractures are the result of significant trauma and

are often associated with considerable soft tissue damage and
with other fractures of the same leg. Urgent stable internal fixa-
tion is today the accepted method of treatment. This will reduce
the risk of pathophysiological complication, as well as help to
prevent permanent impairment of the knee function by early
mobilisation. Medullary nailing, with or without locking, is the
favoured method. Plating, however, has its place in certain frac-
tures, as has external fixation.
7.14.1 Anatomy
Right femur from the front (Fig. 1 a).

Right femur from behind (Fig. 1 b).
Greater trochanter Fovea of head
Head
Neck
Lesser trochanter
Intertrochanteric line
Shaft
Patellar surface Medial supracondylar

Lateral condyle line
Adductor tubercle
1a
• 494
Greater trochanter
Fovea of head
Head -~!-:-
Piriform fossa ----'~=~;l---'J
Neck - - - -..3fo..-
Gluteal tuberosity -------1--

Pectineal line ------fl-
Nutrient foramen -----+--

Linea aspera ------+-
1---- lateral supracondylar line

----'~-- Popliteal surface
-;----->,:>!---- Intercondylar line
Adductor tubercle --t---~- Intercondylar fossa
Lateral condyle
1b
• Li
Li <30'
~30'
2
7.14.2 Assessment
AI A3
A2
Since these patients are often multiply injured, the general
priorities such as respiratory, cardiovascular, cranial, tho-
racic, and abdominal needs are satisfied.
The skeletal injuries should be recognised early and treated
accordingly.
Injuries to the knee ligaments may be involved.
3
81 82 Radiography:
83
- AP view, joints above and below included.
4:::
See also Sect. 5.1 ~
.c
..=
\1:!
-;
Type 32 A : Simple fractures (Fig. 2).
4 Type 32 B: Wedge fractures (Fig. 3). e
Q,j
Cl
C2
C3 Type 32 C: Complex fractures (Fig. 4) . f;lo
495
•
7.14.4 Indications for Osteosynthesis-
Implants of Choice
Fracture:
- High subtrochanteric fracture of the femoral shaft (Types A,
B).
Implants:
- 95 ° condylar plate, 4.5 mm cortex screws as lag screws
(Fig. 5).
- DCS, 4.5 mm cortex screws as lag screws.
Fracture:
- Subtrochanteric fracture of the femoral shaft.
Implants:
- Universal interlocking nail- "closed" method for fractures at
least 2 em distal to the lesser trochanter.
- 95 o condylar plate, 4.5 mm cortex screws as lag screws
(Fig. 6).
Fracture:
- Transverse or short oblique fracture in the middle third (A2,
A3).
Implants:
- Universal interlocking nail, "closed" method.
Fracture:
- Long spiral or butterfly fracture in the middle of the femur.
Implants :
- Universal interlocking nail, closed method (Fig. 7).
- Broad DCP or LC- DCP, 4.5 mm on the dorsolateral aspect of
the bone, with lag screw through the plate if possible, other-
wise separate. Bone graft on the medial side.
Fracture:
- Multifragmentary fracture in the middle of the femur (Type
C).
Implants:
- Universal interlocking nail.
- Broad DCP or LC-DCP as a bridging plate on the dorsolater- 7
~ al aspect of the bone. T he bridging plate is fixed to the intact
.a... distal and proximal part of the bone. Only a few 4.5 mm
f screws are used as lag screws to hold fragments in place.
r.o..
Fracture:
- Open fractures grade 2 and 3. (See alsop. 43)
Implants:
- External fixator.
496
Timing:
- The associated injuries determine the timing for surgery. Ear-
ly stabilisation of the fractured femur will, however, enhance
the ease and quality of the nursing care, and is an important
factor in managing the soft tissue injury.
Positioning:
- Lateral positioning on a vacuum mattress or similar support.
The entire leg is disinfected and draped to allow free move-
ment. The ipsilateral iliac crest is included in the preparation
as donor site for bone graft.
- Supine position may be necessary for the polytraumatised pa-
tient.
- Fracture table, especially for "closed" nailing.
Incision:
- Made on a straight line connecting the greater trochanter
with the lateral femoral condyle. The length depends upon
the location and extent of the fracture. It also depends on fix-
ation method (nail, plate) (Fig. 8).
8 Preparation of instruments:
- Instruments for application of 95 o condylar plate (p. 172).
Greater trochanter - Instruments for insertion of DCS (p. 150).
2 Patella - Instruments for insertion of universal nail and for interlock-
3 Lateral condyle of femur
4 Tuberosity oftibia ing of the nail (pp. 306, 307).
5 Tubercle of GERDY - Instruments for application of DCP, 4.5 mm or LC-DCP, 4.5
mm (p. 112).
- Instruments for application of an external fixator (p. 337).
Simple subtrochanteric fractures and fractures with a butterfly

fragment:
- After exposure using three Hohmann retractors, the bony
landmarks such as the superior of the femoral neck and the
rough line of the greater trochanter are identified.
- A traumatic reduction and fixation of the fracture or the but-
terfly fragment with 4.5 mm cortex screws as lag screws
(p. 77).
- Preparation for and insertion of the 95 o condylar plate
(p. 161) or the DCS (p. 150) A 4.5 mm cortex screw is inserted
through the most proximal plate hole into the calcar to en-
hance the stability of the fixation .
497 •
Complex, multifragmentary high subtrochanteric fractures:
- Exposure and identification of landmarks as above.
- Preparation for and insertion of the condylar plate (p. 161) or
the DCS (p. 150) in the proximal fragment. Fixation with a
4.5 mm cortex screw in the calcar.
- Extensive cancellous bone grafting on the medial side. If graft
is to be used medially, it should be inserted at this stage
through the fracture gaps into the medial soft tissue and be-
fore fracture reduction. Inserting the graft after fixation ne-
cessitates further soft tissue dissection.
- Application of the distractor with the first bolt through the
second proximal plate hole. Distal to the plate the other bolt
is inserted through a predrilled 4.5 mm hole (p. 355).
Through gentle distraction fragments are reduced indirect-
ly. These should preferably be left undisturbed but may be
fixed with lag screws through the plate, provided this does
not destroy the soft tissue attachment. Final fixation of the
plate. See alsop. 18.
Subtrochanteric fractures of the femoral shaft, the fracture line
2 em below the lesser trochanter and fractures in the middle
third:
- For interlocked nailing the patient is positioned either on a
regular table or on a fracture table. An image intensifier is
necessary and has to be correctly placed and draped.
- Reduction of the fracture may be done with the distractor
(p. 355). In "closed" medullary nailing the reduction may be
performed with the patient on the fracture table using distal
femoral skeletal traction and external manipulation.
- Insertion ofthe universal interlocking nail (p. 289).
- Application of a broad DCP or LC-DCP as tension band or
neutralisation plate with lag screw through the plate (pp. 100,
102).
- Application of a broad DCP or LC-DCP as a bridging plate
Open fractures grade 2 and 3 (see alsop. 43).
- Application of an external fixator (p. 331 ).
If open reduction and internal fixation are planned it may be

easier to position the patient on a regular table and use the dis-
tractor for reduction. With the patient on a fracture table and
the extremity in traction, strong tension of the soft tissue makes
exposure, visualisation, retraction and manipulation difficult.
If plate fixation is chosen to stabilise a multifragmentary frac-
ture of the shaft, it may be better to delay surgery for 7-10 days.
It has been stated that during this interval the blood supply to
many of the small fragments will have improved, which may en-
• 498
hance the bone healing. If surgery is to be delayed, the fracture
is splinted and the extremity placed in skeletal traction. This
must be balanced against the disadvantage that 7-10 days of
traction can increase the risk of complications such as fat em-
bolism syndrome and adult respiratory distress syndrome
(ARDS).

- The patient is positioned for the first 4--5 days with the hip
and the knee flexed at 90 o in the so-called 90/90/90/position
(Fig. 9).
- As for intra-articular fractures, continuous passive motion is
beneficial.
- On the 5th postoperative day the patient can sit, and within a
day or two can get up using crutches.
- Partial weight-bearing of 10-15 kg may start. Depending on
progression of healing further weight-bearing is allowed.
9
Implants in weight-bearing bones are in general removed. If

fracture healing has taken place without complications nails and
plates are removed after 24- 36 months.

Miiller ME, Allgower M, Schneider R , Willenegger H (1991) Manual of in-
AO classification offractures of long bones. Springer, Berlin Heidelberg
New York
;:::::
-==
..
rJ:J
';
Q
e
~
~
499
•
7.15 Fractures of the Distal Femur
Supra- and intercondylar fractures present a challenge in that

1 they are difficult to treat both operatively and conservatively.
Younger patients sustain their fractures due to high-energy
' trauma, with soft tissue injury and other fractures. Older pa-
' tients often sustain theirs from a simple fall but their osteo-
. porotic bones make stable fixation difficult. Internal fixation
may be successful if the fracture can be anatomically reduced
and fixed rigidly. This in turn allows early mobilisation which
aids articular cartilage healing and helps prevent stiffness of the
knee joint.
7.15.1 Anatomy
Distal end of the right femur from the front (Fig. 1 a).
Distal end of the right femur from behind (Fig. 1 b).
~---- Lower end of shaft

of femur
Patellar surface
Medial supracondylar line
Lateral condyle
Adductor tubercle
1a
Lower end of shaft of femur - - f - - ' - - - Lateral supracondylar line

-~.--- Popliteal surface
--.,....-->,>,.- Intercondylar line
--t----+1-- Intercondylar fossa
Lateral condyle
1b
.."'=
-..
~
~
e'il
'""'
·.:=
0
....~0
-=
.~
e'il
~
.
~
500
lA
7.15.2 Assessment
w
- Check for knee ligament injuries. This may have to wait until
, - --~-- ,- _... _ __ the femoral fracture has been fixed.
..
r_,......,.. __
) )
\ ).
, ,_, ~
\')..
I
I
A
\ ~ I
I Radiography:
2 I I \ I I I \ f - AP, lateral and oblique views, also of the uninjured side.
A1
A2 AJ
- Tomography.
- CT scan in complex injuries.
- - --""'\ \
l See also Sect.5.1
' (~, I
\ ' l r
3
83
Bl 82 Type 33 A: Extra-articular fracture (Fig. 2).
U
Type 33 B: Partial articular fracture, lateral or medial condyle,
lj: ~
·; sagittal; partial articular fracture, frontal plane
I
~ ·-~.
':: (Fig. 3).
Wfll @~fu
Type 33 C: Complete articular fracture - both condyles sepa-
rate from shaft (Fig. 4).
,- -, r _ .,. ............. _ r - -"""'--
r\ I ~ I .1. I
4 \ ~\ ( \ ~
,, \ I I 1 "'
\I\ I
I
Cl C2 C3 7.15.4 Indications for Osteosynthesis-

Implants of Choice
Fracture:
- Avulsion of the medial collateral ligament from its proximal
insertion together with a piece of bone (Al).
Implant:
- L ag screw fixation with either a small or a large cancellous
5
bone screw combined with the corresponding size spiked
washer (Fig. 5).
Fracture:
- Simple supracondylar fracture (A2) or supracondylar frac-
ture combined with complex fracture of the distal shaft ( A3).
Implants:
- DCS, bone graft in multifragmentary fractures (Fig. 6).
- 95 ° condylar plate, bone graft in multifragmentary fractures
(Fig. 7).
Fractures: ...
- Fracture of the lateral condyle (Bl ). =
5
-
- Frontal fracture of one or both condyles. ~
~
- Tangential posterior fracture (Hoffa fracture) (B3). 'i
6 7
"'
Q
501
•
8
Implants:
- 6.5 mm cancellous bone screws (Fig. 8). 1.tU~ \"Il
- 7.0 mm cannulated screws. Um:t11

- T buttress plate in osteoporotic bone, or with long proximal
llllU:O
extension (Fig. 9).
Fracture:
- TorY fracture (Cl).
- Bicondylar fracture with comminution of the distal shaft
(C2).
Implants:
- DCS (Fig. 10).
- 95 o condylar plate (Fig. 11 ).
Fracture:
- Bicondylar fracture with complex fracture of the distal femur
and additional frontal fracture of one or both condyles.
Implants:
- Condylar buttress plate combined with 7.0 mm cannulated
screws, for the frontal fractures (Fig. 12).
Timing:
- The associated injuries determine the timing of surgical inter-
vention, but the sooner the better. If a delay of a few hours is
necessary the extremity is placed in a splint in skin traction.
Skeletal traction becomes necessary in longer delays.
Positioning:
- Supine with the knee flexed over a roll (60 ° - 90 °) to relax the
gastrocnemius muscle. Hip and knee are draped free.
- Use of a sterile tourniquet may be indicated. 13
1 Lateral condyle of femur
Incision: 2 Head of fibula
3 Tubercle of G ERDY
- Incision along a line joining the greater trochanter, the lateral 4 Tuberosity oftibia
condyle, and the tibial tuberosity (Fig. 13). 5 Common peroneal nerve
• 502
(p. 82).
(p.121).
- Instruments for insertion of 95 o condylar plate (p. 172).
- Instruments for insertion of DCS (p. 150).
- Instruments for application ofT buttress plate (p. 112).
- Instruments for application of condylar buttress plate
(p.112).
7.15.6 Checklist of Operative Technique
Supracondylar fractures without intra-articular extension

(Type A2 and A3):
- Reduction and provisional fixation with Kirschner wires.
- Three further Kirschner wires are inserted. The first is used to
determine the axis of the knee joint parallel to the distal artic-
ular surface of the femoral condyles (1); the second marks the
inclination of the patello-femoral articular surface (2), and
the third the direction of DCS or blade insertion (3). This last
Kirschner wire should be parallel to the first and to the sec-
ond Kirschner in the coronal plane 2 (Fig. 14 and 15).
- Preparation and insertion of the 95 o condylar plate (p. 164)
or DCS (p. 146).
- The fracture is compressed with the aid ofthe articulated ten-
sion device.
- Stability is increased by inserting lag screws across the frac-
ture through the plate.
- In fractures with comminution a cancellous bone graft is ap-
plied on the medial side.
Fractures of the lateral condyle, with and without extension into
the femoral shaft (B1, B2), tangential fracture of the condyles
(B3):
- Anatomical reduction and temporary fixation with Kirschner
wires and reduction forceps.
- In young adults fixation with two 6.5 mm cancellous bone
screws (p. 81) or two 7.0 mm cannulated screws (p. 117) with
32 mm thread. Washers to prevent the screw head from sink-
ing in.
2 Drawing: Wires 1 and 3 are parallel when viewed from in front of femur,
i.e. in the transverse plane. Wires 2 and 3 are parallel when viewed along
long axis of femur, i.e. in the coronal plane. In this way wire 3 is parallel
both to the plane of the tibia-femoral joint (knee extended) as marked by
wire 1, and to the plane of the patellar surface of the femur as marked by
wire2.
503
•
- In tangential fractures the screws are inserted in AP direction
at right angles to the femoral shaft axis. They should be as far
laterally as possible to avoid the articular cartilage. Counter-
sinking for the screw heads may be necessary.
- In osteoporotic bone a T plate is contoured and fixed to the
bone (p. 108).
Supracondylar T or Y fracture, bicondylar fracture with com-
minution of the femoral shaft (C1, C2):
- Careful reduction of the joint fragments and elevation of de-
pressed metaphyseal fragments.
- Temporary fixation with Kirschner wires.
- The entry point of DCS or condylar blade plate is deter-
mined.
- Insertion of two 6.5 mm cancellous bone screws with 32 mm
thread as lag screws, without obstruction of the site for the
DCS or the condylar blade plate. The threads must grip the
far condyle only. Washers prevent the screw heads from sink-
ingin.
- Preparation and insertion of the DCS (p. 146) or the 95 o
condylar plate or (p. 164).
- Extensive cancellous bone graft if there is bone loss medially.
Bicondylar fracture with complex fracture of the distal femoral
shaft and frontal fracture of one or both condyles:
- An additional medial parapatellar incision is necessary if the
medial condyle is fractured.
- The tangential fracture is reduced and fixed with two 6.5 mm
cancellous bone screws (p. 81 ). The thread length depends on
the size of the far fragment.
- Reduction of the condyles and temporary fixation with
Kirschner wires or guide wires for 7.0 mm cannulated screws.
Insertion of any 6.5 mm cancellous bone screws or 7.0 mm
cannulated screws as lag screws (p. 117) that cannot be insert-
ed through the plate.
- Extensive cancellous bone graft is carried out on the medial
side.
- The condylar buttress plate is contoured and applied (p. 109).
Lag screws through the plate increase the stability.
The condylar plate, as well as the DCS, has to be inserted in the

anterior part of the femoral condyles. Since this part is of a
smaller dimension than the posterior aspect, the length of the
condylar plate blade or the DCS screw must be shorter than pro-
jected on a radiograph of the distal femur. Too long an implant
would penetrate the medial cortex, cause synovitis and damage
• 504
the medial capsule, which causes pain and could lead to joint
stiffness (Fig. 16).
In young patients with dense, hard cancellous bone it may be
very difficult to insert the seating chisel without splitting the
supracondylar fragment. Predrilling the slot using a 3.2 mm drill
bit would prevent the splitting.
I I When hammering in the seating chisel in young hard bone one
t
I
~I must apply counter pressure on the medial side to avoid driving
the previously fixed condyles apart.
I \ To reduce the supracondylar fragments the distractor may be
I I used (p. 355). Place the first bolt distally through a plate hole,
J ~ the second proximal to the plate. A slight overdistraction facili-
~B,
tates the careful reduction of the fragments. The plate is fixed to
the main diaphyseal fragment with 4.5 mm cortex screws.
16 t . .' ~ ~' 7.15.8 Postoperative Care

- Immobilisation of the knee in 90 ° flexion for 3-4 days. See
Fig. 9 in Sect. 7.14). Thereafter active flexion and extension
exercises.
- Continuous passive motion for the first 4-7 days is of great
advantage. Thereafter active mobilisation in a functional
brace.
In general, implants in weight-bearing bones are removed after

an uneventful healing process. For implants in the distal femur
the removal may take place after 12- 24 months.
Mast J , Jakob R , Ganz R (1989) Planning and reduction technique in frac-

Mi.iller ME, All gower M, Schneider R , Willenegger H (1991) Manual of in-
Mi.iller ME, Nazarian S, Koch P, Schatzker J (1990) The comprehensive
AO classification of fractures oflong bones. Springer, Berlin Heidelberg
New York
Rtiedi T, H ochstetter AHC, Schlumpf R (1984) Surgical Approaches for
505 •
7.16 Fractures of the Patella
The patella is a sesamoid bone and lies within the tendon of the
quadriceps muscle. Any displaced fracture of the patella in the
longitudinal axis therefore results in loss of function of the ex-
tensor mechanism and should be reduced and internally fixed .
Sometimes osteochondral fractures need surgery to remove an
intra-articular loose body.
7.16.1 Anatomy
Right femur, tibia, fibula and patella, from the front and the side
(Fig. 1).
---- Distal Femur - - - -
Lateral condyle
Patella
Anterior surface ----~H:--
Intercondylar
eminence
Lateral plateau
Tuberosity
Fibula-
7.16.2 Assessment
- Haemarthrosis with fat globules most likely present in joint
aspirate.
- Tenderness when palpating the medial and lateral parapatel-
lar expansions of the quadriceps may indicate that they are
torn and might need repair.
- A palpable gap may be present in the patella.
Radiography:
- AP and horizontal beam lateral views. A fluid level between
the blood and fat may be seen in the joint on this lateral view
indicating an intra-articular fracture.
Intercondylar notch.
- "Skyline "view.
• 506
The patella (together with the mandible, clavicle and scapula) is

in region 9. It is classified 9.1.1. Subtypes and subgroups have
not yet been defined.

Implants of Choice
Fracture:
- Avulsion fracture of the distal pole.
Implants:
- 4.0 mm cancellous bone screw as lag screw, or two longitudi-
nal Kirschner wires, in combination with tension band wire
(Fig. 2).
3 Fracture:
- Simple transverse fracture.
Implants:
- Two Kirschner wires and a tension band wire (Fig. 3).
Fracture :
- Complex fractures.
Implants:
- Two or more Kirschner wires and a tension band wire, some-
times in combination with 4.0 mm cancellous bone screws as
lag screws. In complex fractures patellectomy is an option
(Fig. 4).
Fracture:
- Rupture of the infrapatellar tendon.
Implants:
- Tension band wire and transversely inserted 3.5 mm cortex
screw through the tibial tubercle for distal wire anchorage
(Fig. 5).
Timing:
- As soon as possible, to release haemarthrosis, relieve pain,
and to reduce a displaced patella. Internal fixation is per-
formed at the same time.
Positioning:
- Supine with the leg extended.
- Tourniquet.
507
•
Incision:
- Vertical midline or parapatellar lateral incision (Fig. 6).
- Instruments for insertion of Kirschner wires and
- Instruments for application of tension band wires ( p. 369).
(p. 214).
- Instruments for insertion of3.5 mm cortex screw (p. 215).
Avulsion fracture of the distal pole:

- Anatomical reduction and temporary fixation with the point-
ed reduction forceps.
- Insertion of the 4.0 mm cancellous bone screw as a lag screw
(p. 195). 1 Tuberosity of tibia
- Insertion of Kirschner wires (p. 368). 2 Patellar ligament
3 Infrapatellar branches
- Using a curved large-bore needle the tension band wire is first of saphenous nerve
inserted through the quadriceps tendon close to the bone,
then through the patellar tendon at the lower pole.
- The wire is tightened while palpating the articular surface and
controlling the reduction.
- Flexion of the knee to check compression.
Transverse fractures, simple and complex :
- E levation of any articular depression and filling of defects
with cancellous graft.
- Two parallel longitudinal holes are drilled with the 2.0 mm
drill bit in the proximal fragment close to the anterior surface
of the patella. A 1.6 mm Kirschner wire inserted in the first
drilled hole will ensure that the second is drilled parallel
(p. 368).
- Anatomical reduction and temporary fixation with pointed
reduction forceps.
- Drilling is continued with the 2.0 mm drill bit through the dis-
tal fragment.
- Two 1.6 mm Kirschner wires now bent 180 o at the proximal
ends are inserted.
- The wire loop is passed around the Kirschner wires and tight-
ened with the wire tightener.
- The bent ends of the Kirschner wires are hammered into the
bone and their distal ends cut.
- Fixation of additional fragments with either 4.0 mm cancel-
lous bone screws as lag screws or oblique Kirschner wires.
508
Rupture of the infrapatellar tendon:
- The tendon is repaired with resorbable sutures.
- Protection of the sutures by adding a figure-of-eight tension
band wire: The wire is passed through the quadriceps inser-
tion and the tibial tubercle. In osteoporotic bone, a 3.5 mm
cortex screw is inserted transversely through the tibial tuber-
cle and the tension band wire is wound around each end of the
screw.
A circumferentially placed wire can only hold a fractured patel-

la reduced as long as the knee is not flexed. When flexed, the
fracture gap opens and congruency is lost. Only the tension
band wire passing over the front of the patella ensures compres-
sion across the fracture at all times.
Kirschner wires used to secure fragments must be parallel or im-
paction or compression will not occur.
Only one end of the Kirschner wire should be bent over or re-
moval will require greater dissection.
When repairing the infrapatellar tendon the correct position of
the patella should be checked using preoperative X-ray of the op-
posite knee. A patella baja (low patella) is otherwise produced.
Before wound closure the range of knee flexion is carefully test-
ed whilst the repair is watched. The safe range is recorded in the
operation note.

- If the fixation and the range of motion is satisfactory, active
exercises start immediately.
- Continuous passive motion is recommended, with the arc of
movement carefully set to the safe range as judged at opera-
tion.
- Partial weight-bearing for the first 6 weeks.
- Usually the implants are removed after consolidation of the

fracture at 8-12 months.
- In infrapatellar repair the tension band wire is removed after
6 months.
509
•
Heim U , Pfeiffer KM (1988) Internal fixation of small fragments, 3rd edn.

MUller ME, Allgower M, Schneider R, Willenegger H (1991) Manual of in-
Rtiedi T, Hochstetter AHC, Schlumpf R (1984) Surgical Approaches for
7.17 Fractures of the Tibial Plateau
Fractures of the tibial plateau are intra-articular fractures of a

weight-bearing joint. Any significant disturbance of the joint
surface and damage to the articular cartilage can produce post-
traumatic osteoarthritis. Reconstruction of the joint surface, ax-
ial alignment, internal fixation, and early motion may help pre-
vent this painful complication. The lateral plateau is the one
most often involved. Injuries to vessels, nerves, capsule, collat-
eral and cruciate ligaments as well as to the menisci can be asso-
ciated with these fractures.
7.17.1 Anatomy
Proximal end of the right tibia from the front (Fig. 1).
Tubercles of intercondylar
eminence
Lateral plateau Medial plateau
-'-'-+-- Lateral surlace
• 510
\7 '\1 '1f
~
7.17.2 Assessment
f I . . ·.: I ,~·.- :~
' I
' I •. 1 ' :· -;'
I
2 Special examination:
- Definitive examination is made only after radiography.
AI A2 A3 - Areas of tenderness.
- The state of the anterior skin (local crushing is common and
not always immediately obvious).
- Ligament instability.
- Range of motion, especially abnormal coronal motion.
3
- Careful neuro-vascular assessment.
Bl 82 83
Radiography:
- AP, lateral, and internal and external oblique views.
'Ff\r
- Tomography, AP and lateral views (degree of depression of
\I ..... '
the tibial plateau).
' ,{1
4
- CT scan (comminuted fracture).
Cl C2 C3
See also Sect. 5.1
Type 41 A: Extra-articular fracture, avulsion fractures (Fig. 2).

5
Type 41 B: Partial articular fracture (Fig. 3).
Type 41 C: Complete articular fracture (Fig. 4).

Implants of Choice
6
Fracture:
- Unicondylar fractures (type B), usually lateral side.
Implants:
- Two 6.5 mm cancellous bone screws or 7.0 mm cannulated
screws with washers (in young people) (Fig. 5).
~ L or T buttress plate, lateral tibial head buttress plate, DCP,
or LC-DCP, 4.5 mm (in older people) (Fig. 6).
Fracture:
- Bicondylar fractures (type C).
Implants:
- L or T buttress plate, DCP, or LC-DCP, 4.5 mm, or lateral
7
tibial head buttress plate sometimes combined with three- or
four- hole semi-tubular plate on the medial side as a buttress
(Fig. 7).
- 6.5 mm cancellous bone screws or 7.0 mm cannulated screws,
combined with external fixator in complex or open fractures
8
(Fig. 8).
511 •
Timing:
- Immediately, if an open fracture, an acute compartment syn-
drome, or vascular injury. Simple fractures are also best treat-
edearly.
- If a delay of more than 1-2 days is necessary skeletal traction
prevents telescoping or further displacement of fragments.
Aspiration of haemarthrosis improves comfort.
Positioning:
- Supine with the knee flexed over a roll50-60 °.
- The leg is draped to be freely moved.
- Tourniquet.
Incision:
- Lateral parapatellar approach; with the leg extended the inci-
sion starts over the distal head of the vastus lateralis, contin-
ues just lateral to the patella and its tendon (Fig. 9).
- For complex fractures a long straight anterior midline inci-
sion is used.
(p. 82).
(p.121).
- Instruments for application of Lor T buttress plates (p. 112).
- Instruments for application of DCP or LC-DCP, 4.5 mm
(p. 112). 1 Patella
- Instruments for application of lateral tibial head buttress 2 Tuberosity of tibia
plates (p. 112). 3 Head of fibula
4 Cruciate ligaments
- Instruments for application of semi-tubular plates (p. 112). 5 Medial collateral ligament
- Instruments for application of external fixator ( p. 337). 6 Lateral collateral ligament
- Instruments for harvesting and inserting bone graft (p. 369). 7 Infrapatellar branches
of saphenous nerve
- Instruments for application ofthe femoral distractor (p. 353). 8 Superficial peroneal nerve
7.17.6 Checklist of Operative Technique
Unicondylar or so-called wedge fracture (type B):

- Anatomical reduction and temporary fixation with Kirschner
wires.
- Insertion of two 6.5 mm cancellous bone screws as lag screws
with washers (p. 81), or insertion of two 7.0 mm cannulated
screws as lag screws with washers (p. 117) in young patients.
- In older patients, application of a L or T buttress plate,
(p. 108) DCP, LC-D CP as buttress plate (pp. 101, 106), or lat-
eral tibial head buttress plate with 6.5 mm cancellous bone
screws as lag screws through the plate ( p. 109) .
• 512
Unicondylar or wedge fractures with depression (B 2 and 3):
- Reduction of a central depression by fenestrating the anterior
cortex just in front of fibula using a bone punch. The defect is
packed with cancellous bone.
- In wedge fractures with impaction the large lateral fragment
is rotated laterally and the joint reduced.
- Filling of the defect in the metaphysis with cancellous bone
graft.
- Temporary fixation of the lateral cortex with Kirschner wires.
- Application of the Lor T buttress plate ( p. 108) or lateral tib-
ial head buttress plate ( p. 109).
Bicondylar fractures (Type C1 and C2):
- Reconstruction of the joint and temporary fixation with
pointed reduction forceps or Kirschner wires. Later these are
replaced with 7.0 mm cannulated screws (p. 117).
- Filling of the defect with cancellous bone graft.
- The tibial plateau is joined to the shaft using pointed reduc-
tion forceps or Kirschner wires.
- Application of a three- or four-hole semi-tubular plate to the
medial side ( p. 106).
- Application of the L or T buttress plate to the lateral side
(p. 108).
Complex bicondylar fractures (C3):
- Reconstruction of the joint with 6.5 mm cancellous bone
screws (p. 81 ), or 7.0 mm cannulated screws (p. 117) as lag
screws.
- Bridging of the knee by using an anterior unilateral external
fixation frame. Half-pin fixation away from the fracture fo-
cus if a later fixation of the fracture is necessary after healing
of the soft tissue. Moderate distraction is applied in order to
stabilise the soft tissue by ligamentotaxis. The external fixa-
tor may be reapplied beneath the knee after 2-3 weeks to
allow motion, or internal fixation may be employed as a
secondary procedure depending upon the healing of the soft
tissues.
7.17. 7 Special Consideration - Escape Routes
The distractor is very useful in reduction of most tibial plateau

fractures. In lag screw fixation of a lateral wedge fracture, care
must be taken not to damage the medial articular surface when
inserting the proximal screw. The lateral plateau is higher than
the medial.
In bicondylar fractures the reconstruction should begin with the
simple fracture, which is usually the medial of the two.
513
•
Accurate contouring of the plates is necessary even though
some are preshaped. On the medial side the plate is applied to
the antero-medial face of the proximal metaphysis deep to the
pes anserinus (insertion of the hamstrings into upper tibia) and
the anterior fibres of the medial collateral ligament. On the lat-
eral side, the plate is fixed slightly obliquely with its distal end
flush to the anterior tibial crest and its proximal end as far pos-
tero-lateral as possible.
The menisci must always be tested and repaired if damaged.
The collateral and cruciate ligaments are also tested for laxity.
Medial collateral repair should be carried out at the same time.
Combined cruciate repair is usually not possible.

- Active and passive motion using the continuous passive mo-
tion machine starts immediately if the fixation is stable.
- Partial weight-bearing of 10 kg for the first 3-4 months.
- A hinged functional brace is used when the ligaments, and/or
menisci have been repaired.
As a rule implants in weight-bearing bones are removed after

complete healing. In tibial plateau fractures implants may be re-
moved after 12-18 months, if causing symptoms.

New York
• 514
7.18 Fractures of the Tibial Shaft
The treatment of tibial shaft fractures has long been a question

of controversy. Experience has shown that nonsurgical man-
agement can achieve excellent results especially if the frac-
ture is minimally displaced and reduction can be easily accom-
plished and maintained. The advent of functional bracing
has greatly reduced the cast time in these fractures. In other
instances the treatment with plaster cast or brace fixation
for some months may result in permanent impairment due
to malunion, joint stiffness, and post-thrombotic oedema
formation. The AO/ASIF group has shown that, if based on
sound biomechanical and biological principles, internal or
external fixation has its place in the treatment of tibial shaft
fractures.
Fractures with concomitant vessel or nerve injuries, or compart-
ment syndrome, and open fractures are considered absolute in-
dications for surgical stabilisation. Recommended indications
for internal or external fixation are e. g.:
- Shaft fractures in polytrauma patients requiring intensive
care treatment.
- Unstable fractures with severe displacement of the main frag-
ments.
- Fractures with shortening of more than 1 em.
- Unstable fractures with interposition of muscle, tendon, or
with tilted or rotated bone fragments.
- Segmental fractures.
- Ipsilateral fractures of the femur or severe knee or ankle in-
juries.
- Short oblique fractures associated with a multifragmentary
zone.
-=.c:=
rr:.
-;
:E
E=
515
•
7.18.1 Anatomy
Right tibia and fibula from the front (Fig. 1).
Tubercles of intercondylar
eminence
Lateral plateau Medial plateau
Apex
Head
Neck
Shaft
-+-- Lateral surface
Interosseous border - - H 1---1--- Interosseous border
Fibula
Lateral malleolus Medial malleolus
Inferior articular surface
7.18.2 Assessment
[lj
~ Special examination :
=
ti Soft tissue injuries (open fracture?). The state of the skin is
£ crucial to internal fixation. If in doubt, surgery in closed frac-
~ tures is delayed until signs such as swelling, blisters or contu-
·S sions are not seen on the skin.
....~c Neurological and vascular status (repeated examination) .
Anterior or posterior compartment ischaemia.
-
.i=
~
rz
~
IIIII 516
Radiography:
- AP, lateral views, full length.
~
' . - Tomography, if joint fracture has been diagnosed.
...:::1 • ..6.
~ 30' <30'• - Arteriography, if vascular impairment.
'
•:
2
AI A2 AJ
7.18.3 AO Classification (Tibia/Fibula Diaphysis)
See also Sect. 5 .1
Type 42 A: Simple fracture; spiral, oblique or transverse

(Fig. 2).
Type 42 B: Wedge fracture; spiral-, bending-, or fragmented
3
81 82 83 wedge (Fig. 3).
Type 42 C: Complex fracture; spiral, segmented or irregular
(Fig. 4).

Implants of Choice
4 Fracture:
C2 CJ - Open fractures of the tibial shaft (seep. 43).
Implants:
- External fixator (Fig. 5).
- Unreamed tibial nail (Fig. 6).
Fracture:
- Transverse or short oblique fractures (A2, A3).
Implants:
- Universal tibial nail, unlocked or locked (Fig. 7).
- Lag screw fixation, 4.5 mm-or 3.5 mm cortex screws, in
combination with a 4.5 mm narrow DCP or LC-DCP plate
(Fig. 8).
~
~
.c
5 6 7 8 ~
-;
:s
E=
517
•
Fracture:
- Torsion and bending fractures; spiral or with butterfly frag-
ment (A1, B1-3).
Implants:
- Interlocking universal tibial nail (Fig. 9).
- Lag screw fixation with 4.5 mm or 3.5 mm cortex screws,
and 4.5 mm narrow DCP or LC-DCP as neutralisation plate
(Fig. 10).
- External fixator (in closed fractures with severe soft tissue in-
jury with a potential for compartment syndrome).
Fracture:
- Segmental and comminuted fractures, fibula included
(C1-3).
Implants :
- Lag screw fixation with 4.5 mm or 3.5 mm cortex screws com-
9 10
bined with 4.5 mm DCP or LC-DCP as neutralisation plate.
One-third tubular plate for the low fibular fracture (Fig. 11 ).
- External fixator combined with cancellous bone graft
(Fig. 12).
- Interlocking universal tibial nail (Fig. 13).
12 13
• 518
Timing:
- If possible within 6-8 h after injury before swelling of the ex-
tremity. Otherwise initial stabilisation with, e. g. external fixa-
tor or even plaster splint and delayed surgery for 7-14 days.
Heel traction is used occasionally, but only as a very short-
term measure.
Positioning :
- For intramedullary nailing: Supine on a fracture table with
the knee bent 90 o and extended obliquely downwards. A pad
is used to support the distal femur, avoiding the popliteal
artery and vein (Fig. 14). A heel wire provides traction.
- Supine on a regular table with the knee bent or with hanging
leg.
2
- Image intensification
- For plating or external fixation: Supine on regular table with
the leg supported in slight internal rotation.
- Tourniquet for plating.
I Tuberosity
of tibia Incision :
2 Patell;lr
ligament - For "closed" nailing: A 60 mm longitudinal incision medial to
3 lnfrapate llar the patellar tendon is made. The tendon is retracted about 20
branches of saphenous mm laterally (Fig. 15).
nerve
- For plating: The incision is parallel and 10-15 mm lateral to
the anterior tibial crest, extending from the tibial tuberosity
to 3 finger breadths above the ankle joint (Fig. 16). Some-
1 Tuberosity times a postero-medial incision is chosen, mostly in sec-
of tibia
2 Anterior ondary procedures to insert bone graft (Fig. 17).
border
3 Medial Preparation of instruments:
malleolus - Instruments for the application of the external fixator
(p. 337).
Instruments for insertion of the unreamed tibial nail (UTN)
(p. 319).
- Instruments for insertion of the universal tibial nail, unlocked
and locked (pp. 307, 308).
- Instruments for application of 4.5 mm DCP or LC-DCP and
semi-tubular plate (p. 112).
- Instruments for insertion of 4.5 mm cortex screws as lag
screws (p. 77).
2--- as lag screws (p. 81 ).
17 screws (p. 196).
1 Medial condyle of tibia - Instrument for application of a one-third tubular plate
2 Medial malleolus (p. 201).
3 Soleus muscle
3 4 Gastrocnemius muscle
5 Calcaneal tendon
16 (Achilles tendon)
519 •
Intramedullary nailing for closed tibial fractures; "closed" or

open method:
- In proximal fractures careful and accurate reduction must be
carried out to prevent angulation of the proximal fragment. A
distract or may be applied to counteract the pull of the patella
tendon (p. 355).
- Insertion of the universal tibial nail; unlocked in simple frac-
tures of the middle third, locked in fractures of the proximal
and distal thirds or in complex fractures (p. 297).
- In segmental fractures, reaming may be left out to avoid spin-
ning the fragments, and an unreamed tibial nail used.
Plating of a distal tibial shaft fracture:
- Anatomical reduction and temporary fixation with bone-
holding forceps. A posterior butterfly fragment is best held
with a cerclage wire.
- Insertion of separate 4.5 mm cortex screws as lag screws
(p. 77) in spiral or oblique fractures.
- Application of a 4.5 mm DCP or LC-DCP (pp. 98, 103).
- Application of the one-third tubular plate in a concomitant
low fibular fracture (p. 200)
Plating of a transverse or short oblique fracture of the proximal
tibia:
- Anatomical reduction
- Application of a DCP or LC-DCP with lag screw through the
plate. Fixation in at least six cortices in each main fragment. If
such a proximal diaphyseal fracture is associated with a
plateau injury, a lateral tibial head buttress plate is ideal; this
has a thin plate section for the metaphyseal zone and a shaft
of 4.5 mm DCP configuration that provides strength for the
diaphysis (p. 109).
- Application of a short semi-tubular plate on the anterior tib-
ial crest to neutralise the bending forces in the sagittal plane
(p. 106).
External fixation:
In open fractures (seep. 43).
- Application of the external fixator; unilateral single-or dou-
~ ble bar frame, unilateral two-plane (V-shaped) frame
"tj (p. 329).
~ - Cancellous bone graft in complex fractures (p. 371 ).
"'
.9...=
~
'0
.9=
~
~
• 520
Unreamed tibial nailing, "closed" technique:
- Technique as for reamed nailing but without the reaming.
The nail should be inserted with hand pressure only or at the
most a few light hammer blows. Always locked proximally
and distally with 3.9 mm locking bolts (p. 315).
For intramedullary nailing, the correct position of the reaming

rod within the medullary canal is verified before reaming starts.
The reamer may otherwise penetrate the posterior wall and
cause severe damage to the soft tissue. Reaming should be min-
imised or avoided in multifragmentary fractures. Locking of the
nail is then recommended proximally and distally. Excessive
force must not be used when driving in the nail or it may shatter
the posterior cortex. The nail should be inserted as parallel as
possible to the long axis of the tibia so as to slide along the back
of the anterior cortex.
For lag screw fixation and plating, incisions should not be made
through traumatised skin and soft tissue, or directly over a sub-
cutaneous bone. The skin is poorly vascularised in this area and
skin breakdown not uncommon. Stripping of the periosteum
must be avoided since the blood supply may be damaged. In
most instances it is better to use 3.5 mm cortex screws as sepa-
rate lag screws, especially in butterfly fragments. These screws
are inserted first, then a plate is added. If the plate screws are
crossing the fracture they are inserted as lag screws. If lag screw
fixation of fragments is stable, it is not necessary to fill all plate
holes with screws. If a plate hole comes to lie over a fracture line,
the near cortex should be drilled to 4.5 mm to avoid spreading
of the cortex. The screw will then grip only in the far cortex. The
wound should be closed with an atraumatic, tension-free tech-
nique. If tension has to be applied to close the wound, it is safer
to leave a portion of the wound open to avoid skin necrosis. Ten-
dons, nerves, and blood vessels, however, should not be left
exposed.
In external fixation, the fixator should be applied within the
"safe corridor" (seep. 329). Bilateral frames with pins crossing
the anterior compartment are not recommended. Complica-
tions such as compartment syndrome, injuries to neuro-vascular
structures, and muscle function impairment may be the result.
ct:
=
-
.:
tl.l
.....c=
E=
521
•

- The leg is elevated on a padded frame with the knee flexed to
45 o and the ankle to 90 o (Fig. 18).
- If the fracture is stable and no other complication is expected,
motion can start early.
- The splint is removed on the second postoperative day and
the patient encouraged to move the ankle.
18
In general, stainless steel implants in weight-bearing bones are

removed after an uncomplicated healing process. Separate
screws and titanium implants may be left in place if symptom-
less. The time for removal depends on the fracture type and the
course of healing. Medullary nails can be removed after 18-24
months, plates after 12-18 months.
Mi.iller ME, Allgower M, Schneider R, Willenegger H (1991) Manual of in-

Mi.iller ME, Nazarian S, Koch P, Schatzker J (1990) The comprehensive
New York
Ri.iedi T, H ochstetter AHC, Schlumpf R (1984) Surgical Approaches for
Schatzker J , Tile M (1987) The rationale of operative fracture care.
-...
..."'
~
=
(j
~
r.o.
"'0
·c=
...~
0
-
~
=
.~
~
~
• 522
7.19 Fractures of the Distal Tibia "Pilon Fractures"
Both tibia and fibula can be involved in this fracture type. If dis-
placed, these fractures are difficult to treat and present a chal-
lenge to the operating team. The fracture is often caused by high
energy trauma, for example, a fall from a height, or a motor ve-
hicle accident. It can involve both compressive and shearing
forces which can lead to severe impaction of the cancellous
bone, disruption of the articular surface, and a fractured fibula.
In for example ski injuries the fracture is the result of shearing
forces which makes it grossly unstable. The condition of the skin
and the soft tissue will also greatly influence the choice of the
treatment. Fractures with minimal displacement and an intact
joint surface are best treated conservatively in a cast and later a
brace, or with an external fixator for a brief initial period before
gentle active motion starts at 3-4 weeks.
Anterior tubercle
(Tillaux-Chaput)
7.19.1 Anatomy
Medial malleclus
Inferior articular surtace Distal end of the right tibia from the front (Fig. 1).
7.19.2 Assessment
'
.
2
~~
,;
- Neuro-vascular status.
- Skin and soft tissue condition.
Radiography:
Al A2 A3 - AP, lateral and oblique views.
- AP and lateral tomography.
\k
- CT (articular surface damage).
111
~U~
\) ( ' 7.19.3 AO Classification (Tibia/Fibula Distal)
3
See also Sect. 5.1
81 82 83
i
Type 43 A: Extra-articular fracture, metaphyseal simple,
.
. wedge, or complex (Fig. 2) .
J Type 43 B: Partial articular fracture, split and/or depression
I
(Fig. 3).
Cr-~~ ~
I I,
Type 43 C: Complete articular fracture; simple, multifragmen-
tary (Fig. 4).
4
Cl C2 C3
523 •
Implants of Choice
Fracture:
- Fibular fracture and explosion fracture of distal tibia (most
often young patients) or impaction fracture of distal tibia
(mostly elderly).
Implants:
- For the fibular fracture : One-third tubular plate (Fig. 5).
- For the tibial fracture: 4.0 mm cancellous bone screws, or 3.5
mm cannulated screws.
- T plate, cloverleaf plate, DCP or LC-DCP, 4.5 mm
- External fixation, especially if the skin condition is poor
(Fig. 6).
Timing:
- As soon as possible, before severe soft tissue swelling and
fracture blisters occur. If this is the case, the fracture is sta-
bilised with traction or external fixation to maintain length. 6
Surgery is delayed for 7-10 days or until the skin recovers.

Positioning:
- Supine; tourniquet.
Incision:
- Medial side: The incision starts lateral to the anterior crest of
the tibia curves around and 1-2 finger widths from the anteri-
or edge of the medial malleolus to a point 1-2 em distal to the
tip of the malleolus (Fig. 7).
- Lateral side: If a second incision is needed there should be a
7 em skin bridge between the two. The incision is made poste-
riorly.
- Instruments for application of one-third tubular plate
(p. 216).
- Instruments for insertion of 4.0 mm cancellous bone screws 7
(p. 214). 1 Anterior border of tibia
2 Medial malleolus
3 Ankle joint ( talocrural joint)
(p. 134). 4 Saphenous nerve
- Instruments for application ofT plate (p. 112).
- Instruments for application of cloverleaf plate (p. 112 and/or
216).
(p. 112).
- Instruments for application of external fixator (p. 327) .
• 524
With fibula and tibia fractures:

- Anatomical reduction of the fibular fracture. If possible 3.5
mmcortex
screws as lag screws, and then the one-third tubular plate
(p. 200).
- Reconstruction and temporary fixation of the joint surface
with Kirschner wires.
- Fixation with 4.0 mm cancellous bone screws as lag screws
(p.195), or
- Fixation with 3.5 mm cannulated screws over preplaced
guide pins (p. 133).
- Application of cancellous bone graft in bone cavity.
- Application of a medial buttress plate; T plate (p. 108), a clo-
verleaf plate (p. 212), DCP or LC-DCP (pp. 101, 106). The
siting of the plate will depend on the direction in which the
joint surface would angulate if deformity occurred. If varus
collapse is to be avoided a medial buttress is needed, but if an-
terior collapse is feared the plate should be on the front of the
distal tibia.
- Application of a bilateral external fixator (p. 335).
An X-ray of the intact side for comparison is essential when re-

constructing a complex fracture. Restoration of the fibular
length is essential. The distractor or the external fixator may
facilitate reconstruction of the fracture by ligamentotaxis and
indirect reduction. The lower pin is placed in the talar notch
(Fig. 8).
When cancellous bone grafting is indicated, harvesting the bone
graft is best done before reconstruction of the fracture starts.
8 The operating- and tourniquet time on the pilon fracture can
thus be shortened. A cloverleaf plate can be cut to the desired
shape for the distal part of the tibia. Newly designed plates are
fixed with small fragment screws only. The former design of the
cloverleaf plate allowed the use of 4.5 mm cortex screws in the
diaphyseal portion of the implant. Many of these older implants
are still in use.
The wounds should be closed without tension, or else skin
necrosis can cause major surgical disaster. If this is impossible,
part of, or the entire, lateral incision is left open for 5-10 days. In
old patients with osteoporotic bone, it may be necessary to use
bone cement to hold screws.
525 •

- The legis placed in a double U-splint with the ankle in 90° to
prevent equinus deformity for the first few days (Fig. 9). The
extremity is kept elevated to reduce swelling.
- If the fracture is stable, motion is started immediately with
dorsiflexion and delayed weight-bearing. In comminuted in-
tra-articular fractures weight-bearing can only start after firm
union; that is after 8- 12 weeks.
A walking calliper, which takes the weight off the pilon, is rec-
ommended for the long period of reduced or partial weight-
bearing. See SYNTHES cataloque
Single screws and titanium implants may be left in place. Other

implants can be removed after 12-18 months if the healing pro-
cess has been uncomplicated.
Heim U (1991) Die Pilon-tibial-Fraktur. Springer, Berlin Heidelberg New

York
Muller ME, AllgowerM, Schneider R, Willenegger H(1991) Manual ofin-
ternalfixation, 3rd edn.'Springer, Berlin HeidelbergNewYork
New York
Riiedi T, Hochstetler AHC, Schlumpf R (1984) Surgical Approaches for
Springer, BerlinHeidelberg New York
-=...=
CIJ.
...
Q,)
~
CIJ.
...=
·=~
...
-
Q
=
·=
=
.~
~
• 526
7.20 Malleolar Fractures
Malleolar fractures are among the most common skeletal in-

juries. They may be caused by direct force but most often they
occur with minimal violence resulting from a subluxation or dis-
location of the talus out of the ankle mortise. These fractures
are often a combination of injuries to the fibula and/or tibia, the
joint cartilage, the ligaments, and the capsule.
The operative treatment of malleolar fractures has long been
disputed. It is, however, felt that anatomical reduction and exact
reconstruction of the ankle mortise is a necessity to avoid a later
post -traumatic osteoarthritis in unstable malleolar injuries.
7.20.1 Anatomy
Lower end of the right tibia from the front (Fig. 1).
Two groups of ligaments are involved:
- The inferior tibio-fibular ligamentous complex, consists of
three elements:
The anterior syndesmotic ligament, (anterior tibio-fibular
ligament).
The posterior syndesmotic ligament (posterior tibio-fibular
ligament).
The interosseous membrane (Fig. 2).
Lower end of fibula Anterior tibial tubercle

(Tillaux-Chaput)
Medial malleolus
Lateral malleolus Inferior articular surface
l•O· tib10fib. lig, t1bi0f1b

antenu.s poste"vs
527 •
The collateral ligaments:
The lateral collateral ligament, with three divisions (Fig. 3.).
The medial collateral, or deltoid, ligament, with two divisions.
7.20.2 Assessment
- Condition of the skin.
- Points of tenderness. If over a ligament or capsule, injury is
likely to be present.
- The whole fibular shaft must be palpated for tenderness as in
~
some type C injuries the fibular fracture may be in the upper
third.
~ ~ ~
- Abnormal motion of the talus in the ankle mortise.
.
-::::,
Radiography: I I
- AP, and lateral views. ~-- ~=-~ --'

Q20
;
1 ( I (
- Mortise view, taken at 15 o internal rotation for proper view of '--) ,_! 4
the inferior tibio-fibular syndesmosis, and the tala-fibular ar-
Al A2 A3
ticulation.
- Tomograms, to assess the degree of comminution and a possi-
ble talar dome fracture.
See also Sect. 5.1 ~i9-
I...... ..J
Bl
\
_,
B2
I
B3
-==
..."' Type 44 A: Infrasyndesmotic fibular lesion with or without
~
fracture of the medial malleolus (Fig. 4).

( .J
...
r-.
Type 44 B: Transsyndesmotic isolated fibular fracture, with
medial lesion, and/or with postero-lateral tibia
"'
....9= (Volkmann's) fracture (Fig. 5) .
Type 44 C: Suprasyndesmotic lesion with simple or multifrag-
....~c mentary diaphyseal fibular fracture, or proximal
-=
.9=
fibular fracture, and with medial disruption (Fig. 6).
l 6
~ '--'
1Z Cl C2 C3
• 528
Implants of Choice
Fracture:
- Infrasyndesmotic fibular fracture, short oblique or trans-
verse, and vertical fracture of the medial malleolus (type A).
Implants:
- Kirschner wires, 1.6 mm diameter, and figure-of-eight ten-
sion band wires, 1.2 mm diameter for fibula (Fig. 7). For a
larger fragment a one-third tubular plate.
- 4.0 mm cancellous bone screws, or 4.5 mm cannulated screws
8 as lag screws for medial malleolus (Fig. 8).
Fracture:
- Transsyndesmotic fibular fracture, medial malleolar fracture,
postero-lateral tibia fragment (type B).
Implants:
3.5 mm cortex screws as lag screws in oblique fractures of the
fibula.
Contoured one-third tubular plate in multifragmentary fibu-
lar fracture and to neutralise lag screw fixation
- Kirschner wires, 1.6 mm diameter, and 1.2 mm cerclage wire
for tension band wiring of the medial malleolus.
9 - 4.0 mm cancellous bone screws, or 4.5 mm cannulated screws
for lag screw fixation of the medial malleolus and postero-lat-
eral tibia fragment
- 6.5 mm cancellous bone screw for the postero-lateral tibia
fragment (Fig. 9).
Fracture :
- Suprasyndesmotic comminuted fibular fracture, and medial
malleolar fracture, postero-lateral tibia fragment.
Implants:
- One-third tubular plate, 8- 12 holes, for the fibular fracture.
~ - 4.0 mm cancellous bone screws, or 4.5 mm cannulated screws
_f. ~': _.: i/ for the medial malleolar fracture .
- Kirschner wires, 1.6 mm diameter, and figure of eight wire,
1.2 mm diameter for medial malleolar fracture.
- 6.5 mm cancellous bone screw for the postero-lateral tibia
fragment.
- 3.5 mm cortex screw as transfixation screw (Fig. 10).
..=
-..
CIJ
~
..
~
f;l;,
~
Q
..2:!
10 -;
~
529
•
Timing:
- If possible within 6-8 h following injury. If the skin shows
oedema and/or blisters surgery is postponed until skin condi-
tion has improved. The fracture is reduced and immobilised
in a well-padded plaster cast. The leg is kept elevated. Open 11---H-- - 6
reduction is undertaken when the swelling has subsided after :a'2i~l===.!~ 7

4-6 days.
Positioning:
- Supine, with the leg in slight internal rotation.
- Tourniquet.
Incision:
- Lateral malleolus: A straight or hockey stick incision about 1 Peroneal nerve
2 Lateral calcaneal branches
10 em long is made anteriorly (be careful of the superficial of peroneal nerve
peroneal nerve!) or posterior (be careful of the sural nerve 3 Lateral dorsal cutaneous nerve
and the small saphenous vein!) to the palpable lateral malleo- 4 Intermediate dorsal cutaneous nerve
5 Lateral malleolus
lus (Fig. 11 ). 6 "TUbercle of Chaput"
- Medial malleolus: The incision curves behind and 1 finger 7 Anterior tala-fibular ligament
breadths from the posterior edge of the medial malleolus to a 8 Calcanea-fibular ligament
9 Lateral talo-calcaneal ligament
point 1-2 em distal to its tip (Fig. 12).
- For fixation of the Volkmann's fracture: The lateral incision is
extended proximally curving it back to the Achilles tendon.
Wedge cushion underneath the buttock.
- Instruments for tension band wiring (p. 369).
- Instruments for application of a one-third tubular plate
(p. 216).
screws (p. 215).
as lag screws (p. 214).
(p. 128).
as lag screws (p. 82).
- Instruments for insertion of 3.5 mm cortex screws as transfix-
ation screws (p. 215). 1 Anterior border of tibia
2 Medial malleolus
3 Ankle joint (talocruraljoint)
4 Saphenous nerve
Type A and B fractures:

- Anatomical reduction of the fibula and temporary fixation
with a pointed reduction forceps.
- Fixation of the fibular fracture by tension band wiring
(p. 366), or one-third tubular plate (p. 200) .
• 530
- Exposure of the medial malleolus and careful reflexion of any
trapped periosteum.
- Reduction of any impaction fracture of the articular surface
of the tibia and bone grafting of a resulting cancellous bone
defect.
- Fixation of the medial malleolus by tension band wiring
(small transverse avulsion fragment), or by 4.0 mm can-
cellous bone screws as lag screws (large shear fragment)
(p. 195), or 4.5 mm cannulated screws (p. 126).
- Reduction and provisional fixation of posterior fragment by
Kirschner wire.
- Final fixation by 4.0 mm cancellous bone screws as lag screws
in antero-posterior direction.
- Suturing of torn ligaments, usually only the lateral ligament
in type A injuries.
Type C fractures:
- Anatomical reduction and fixation of the fibular shaft frac-
ture with 3.5 mm cortex screws as lag screws (p. 196), in com-
bination with a one-third tubular plate (p. 201 ).
- Exposure of the anterior syndesmosis. Lag screw fixation if
avulsed from the bone (tubercle of Tillaux-Chaput), other-
wise possible suture ofligament.
- If instability persists, a 3.5 mm cortex screw is inserted as a
fibula-tibial transfixation (positioning)screw about 2-3 em
above the ankle. The screw is inserted obliquely at an angle of
25 o- 30 o starting postero-laterally and aiming antero-medi-
ally. Such a screw is threaded in the fibular and tibial cortices.
It is not a lag screw (p. 197).
- Fixation of the medial malleolus and any postero-lateral frag-
ment as described for type B fractures.
In type C fractures with a very high fibular fracture, exposure

may not be necessary. Using a hook or a pointed reduction for-
ceps the fibula is reduced down into its normal position and sta-
bilised here with a Kirschner wire. A transfixation screw is in-
serted as described above, after checking fibular length and
rotation by X-ray and exposure of the anterior syndesmosis.
-==
..."'
~
1;,1
...
...
~
=
Q
~
-;
~
531
•

- Splinting of the ankle at 90 a in a plaster of Paris back -slab to
prevent equinus deformity (Fig. 9, p. 526).
- Elevation of the limb (Fig. 8, p. 522).
- Active mobilisation out of the splint starts at 24-36 h. The
splint is discarded and partial weight bearing (10-15 kg) start-
ed as soon as the clinical situation allows, usually after the
fourth to tenth postoperative day.
- For protection a plaster cast may have to be applied when pa-
tients considered unreliable are discharged. Full weight-bear-
ing is normally possible after 8-10 weeks.
Usually the implants are removed after 8-12 months. Single lag
screws may be left in if not causing discomfort. Transfixation
screws are removed no later than 8-12 weeks after internal fixa-
tion, and always prior to unprotected full weight-bearing.

New York
.
"'
-
~
=
...=.
~
=
"'0
·c
....~0
=
0
i1<1
~
• 532
7.21 Fractures of the Foot
As in all displaced intra-articular fractures, anatomical reduc-

tion, stable fixation and early motion is essential in the foot.
Normal gait is otherwise impossible and post-traumatic arthritis
often the result. Internal fixation of some of these fractures will
be discussed.
7.21.1 Anatomy
Right foot from above and in front (Fig. 1).
--< - First tarsometatarsal joint
Metatarsals
_ Metatarsophalangeal
joint of great toe
Proximal interphalangeal joint -
Distal interphalangeal joint - -
Interphalangeal
Little toe joint of great toe
Second toe
7.21.2 Assessment
- Skin condition, swelling.
- Localised bony tenderness or deformity.
- Vascular status of the foot in severely deformed or crush
injuries.
Radiography:
- AP, lateral and oblique views
- Tomograms (comminution of the neck, or body, of the talus
or calcaneus and incongruity of the sub-talar joint).
- CT scan (calcaneus fractures) .
533 •
The foot is in the anatomical zone 8. The subtypes and sub-

groups are not yet defined.

Implants of Choice
Fracture:
- Talus fractures
Implants:
6.5 mm cancellous bone screws or large cannulated screws as
lag screws (neck fracture) (Fig. 2).
4.5 mm cortex screws or 4.5 mm cannulated screws as lag
screws (neck fracture in smaller bones) (Fig. 3).
- 3.5 mm cortex screws or 3.5 mm cannulated screws as lag
screws (posterior body or neck fracture) (Fig. 4).
Fracture:
- Calcaneus fractures.
Implants:
- 3.5 mm cortex or cannulated screws, or 4.5 mm cannulated
screws as lag screws (medial fragment including sustentacu-
lum tali) (Fig. 5).
- Reconstruction plate, 3.5 mm (and/or cervical spine plate)
(Fig. 6).
.."'=
-.
~
~
C'll
~
=
"'
·c0
~
.....
-=
0
·=C'll
~
f.i:
• 534
Fracture:
- Tarsometatarsal dislocations.
Implants:
- Kirschner wires (minimal displacement).
- 3.5 mm cortex or cannulated screws as lag screws (in the
first, second and fifth metatarsal with marked displacement)
(Fig. 7).
Fracture:
- Metatarsal fractures.
Implants:
- Kirschner wires, especially in the third and fourth metatarsal
(Fig. 8).
- 2.7 mm cortex screws as lag screws in the metaphysis of the
first and sometimes in the fifth metatarsals.
- Quarter-tubular plate or DCP, 2.7 mm in shaft fractures of the
metatarsals.
- 2.7 mm condylar plate in fractures of the distal first
metatarsal.
Fracture:
- Metatarsophalangeal joint fractures.
Implants:
- Kirschner wires
- 2.7 mm cortex screw as lag screw in fractures of the base of the
first phalanx (Fig. 9).
Timing:
Unless there are skin problems internal fixation is performed
immediately. If surgery is delayed, displaced fractures must
be reduced and kept elevated.
Positioning:
- Supine, tourniquet. The approach to a calcaneus fracture
may be easier with the patient on the side or with padding un-
der the buttock.
-
0
...
0
535 •
Incisions (Fig. 103):
Talus fracture: Lateral transverse or oblique, medial linear
incision
Calcaneus fracture: Lateral straight, or curved L-or J- shaped
incision, medial straight incision about 1 em inferior to the
line of the posterior tibial tendon.
Tarsometatarsal fracture dislocations: One to three dorsal
linear incisions, 3-4 em long, centred about 1 em distal to the
joint line. They are made between the first and the second
metatarsals, the third and the fourth, and laterally over the
fifth metatarsal base.
Metatarsal fractures: Straight dorsal linear incisions.
STANDARD INCISIONS
SURAL NERVE
LATERAL
LATERAL DORSAL TARSO-METATARSAL
STAB
ANTERO MEDIAL ANKLE
MEDIAL OR LATERAL
LESSER TOE INCISION
STAB
PLANTAR MEDIAL DORSAL FIRST
"'~ 10
=
! ~
·c0
....~0
=
=
~
0
3With the kind permission of Sigward T. Hansen, Harborview Medical
Centre, Seattle, USA .
• 536
(p. 82).
(p. 121).
- Instruments for insertion of 4.5 mm cortex screws (p. 82).
(p. 128).
- Instruments for insertion of 3.5 mm cortex screws (p. 215).
(p. 134).
- Instruments for application of reconstruction plates, 3.5 mm
and cervical spine plates (p. 216).
- Instruments for insertion of Kirschner wires (p. 369).
Talus fractures:
- Anatomical reduction, closed or open, and provisional fixa-
tion with Kirschner wires.
- Insertion of a 6.5 mm cancellous bone screw as a lag screw
from a posterior direction (neck fractures). A 4.5 mm drill bit
is used to drill a gliding hole for the shaft in the dense bone of
the talus (p. 81). A 7.0 mmcannulatedscrewcan be used as an
alternative (p. 117) A Kirschner wire is inserted parallel to
prevent rotation.
- Insertion of 3.5 mm cortex screws or 4.0 mm cancellous bone
screws as lag screws (195, 196) from the medial side in com-
plex fractures.
- Cancellous bone grafting of gaps.
Calcaneus fractures:
- Open anatomical reduction and provisional fixation with
Kirschner wires.
- Insertion of 3.5 mm cortex or cannulated screws as lag screws
in moderately displaced fractures (pp. 133, 196). The screws
placed in the area under the sinus tarsi should catch the sus-
tentacular fragment securely. Thus, the more anterior screw
is angled upwards. The posterior screw is angled downwards
into the dense area of the bone. 4.5 mm screws may be used as
well.
- Application of a reconstruction plate, 3.5 mm (and/or cervi-
cal spine plate) in complex fractures.
Tarsometatarsal fracture dislocations:
- Open anatomical reduction and provisional fixation with
Kirschner wires and/or reduction forceps in fractures with
marked displacement or joint dislocation.
-
0
~
537
•
- A small notch is cut into the dorsum of the metatarsal1-1.5
em distal to the joint.
- Insertion of 3.5 mm cortex or cannulated screws as lag screws
perpendicularly across the joint (p. 133, 196). The drill hole is
placed at the upper end of the notch to prevent splitting the
base of the metatarsal. Screws are used for fixation of the first,
the second, and possibly of the fifth metatarsals.
- Insertion of Kirschner wires in the third and fourth
metatarsals.
Metatarsal fractures:
- Open anatomical reduction of the first and fifth metatarsal.
- Application of a one-third tubular plate straight dorsally or
medially on the first metatarsal (p. 200).
- Application of a quarter-tubular plate laterally 2.7 mm DCP
on the fifth metatarsal.
- Insertion of Kirschner wires in the third and fourth meta-
tarsals in correct direction to prevent extension deformity:
The fracture is opened and the wire run distally just under the
dorsal cortex parallel to the axis ofthe bone (see Fig. 8). The
fracture is reduced and the wire driven retrograde beneath
the dorsal cortex.
In talus fractures it is extremely important that the blood supply

be preserved. Any stripping of soft tissue across the dorsum of
the neck and head region or in the sinus tarsi must be avoided.

- Talus fractures: A 90 o splint is applied ifthere is doubt about
the stability of the fixation and the quality of the bone stock.
On the second postoperative day gentle, active motion can
start after removal of the splint. The splint is kept during the
night.
- Calcaneus fractures: The foot is kept elevated 3-4 days with a
bivalved cast at 90 o during the night to prevent equinus. Early
gentle, active mobilisation with frequent inversion/eversion
exercises. Touch weight-bearing is allowed.
- Tarsometatarsal fracture dislocations and metatarsal frac-
tures: Elevation of the foot in a bivalved cast, which allows ac-
tive motion during the day. This is kept during the night for
some weeks. Partial weight-bearing of about 10 kg. After 6-8
weeks full weight bearing can start.
• 538
In talus and calcaneus fractures, screws and plates are removed

after 8-12 months if symptomatic. In tarsometatarsal frac-
ture/dislocation the screws are removed after 12-14 weeks,
since the joint is not fused and motion will eventually cause the
screws to fatigue. In metatarsal fractures the Kirschner wires
are removed after 4 weeks. Other implants may be left in if
there is no discomfort to the patient.

-
Q
Q
~
539 •
7.22 References
Colton CL, Hall AJ (1991) Atlas of orthopedic surgical approaches. But-

terworth- Heinemann, Oxford
Fernandez Dell'Oca (1989) Modular external fixation in emergency with
the AO tubular system. Intergraf, Montevideo
Heim U (1991) Die Pilon-tibial-Fraktur. Springer, Berlin Heidelberg New
York
Hierholzer G, Ruedi T, Allgower M, Schatzker 1 (1985) Manual on the
AO/ASIF tubular external fixator. Springer, Berlin Heidelberg New
York
Muller ME, Nazarian S, Koch P, Schatzker 1 (1990) The comprehensive
New York
Regazzoni P, Ruedi T, Winquist R, Allgower M (1985) The dynamic hip
screw implant system. Springer, Berlin Heidelberg New York
"'...
~
....=
t.J
~
...
~
"'
·=...=
~
.....
Q
=
·=....
~
;.!
fi:
• 540
8 AO/ASIF Technique
in Late Reconstructive Surgery
By R. Hertel
8.1 Post-traumatic Deformities
8.1.1 Malunion
A malunited fracture is defined as a fracture which has healed

with an abnormal position of the fragments. Depending on its
location a malunion may impair function and appearance. The
most serious problems are intra-articular malunions with steps
in the subchondral bone plate. Untreated, these may lead to
joint degeneration. Metaphyseal and diaphyseal malunions
may result in shortening, angular or rotational deformities. The
deformity itself is often painless, although neighbouring, or
even distant, joints may be affected by the resulting unphysio-
logical load distribution, leading to chronic pain and to progres-
sive osteoarthritis.
Malunions are caused by inadequate primary reduction or by
unrecognised secondary displacement due to ineffective immo-
bilisation during healing.
In children, post-traumatic deformities may occur despite per-
fect reduction and healing in an anatomical position. This is es-
pecially true when the growth plate is injured, which may lead to
a variable degree of growth disturbance.
I
uh:r Treatment is indicated when function is jeopardised and when
I
I serious complications can be anticipated. Whenever possible,
b nf correction should be done at the site of the deformity. In special
I
Malunion of the distal radius. a Typical defor- cases the correction can best be achieved by creating a second
mity after untreated Colles' fracture. There is a deformity which will counterbalance the first. Fixation is
dorsal and radial tilt of the articular surface. achieved by plate, intramedullary (i. m.) nail or with an external
b Osteotomy is performed at the site of deformity. fixator.
A biplanar corticocancellous wedge is interposed
and a 3.5 mm T plate is used to stabilise the recon- Prevention is best achieved by careful primary treatment and
structed bone. close follow-up in cases of relative instability.
-=e
.~
~
-
E
"'
Q
I
=-
541 •
8.1.2 Delayed Union, Nonunion
The time it takes for a fracture to heal depends on several fac-

tors. The most important are the site (metaphyseal or diaphy-
seal), the type of fracture including the mechanism of injury, the
soft tissue injury, the amount of tissue devascularisation, associ-
ated trauma, the general condition of the patient, medication
such as steroids and anticoagulants and the type of treatment.
Union is considered delayed when healing has not progressed in
the average time for a given fracture situation. As a general rule,
if a fracture has not healed by 4--6 months there is delayed
union. Nonunion is present when consolidation has ceased to
progress. This is generally the case after 6-8 months. The final
stage may be the development of a frank pseudarthrosis. This
false joint may be lined by fibrocartilage and have a joint cap-
sule.
Reasons for nonunion can be summarised as biological and me-
chanical. Biological factors are an insufficient tissue response,
usually due to excessive devascularisation of the bone and soft
tissues, the presence of interposed tissue or an infection. Me-
chanical factors include too much relative motion at the fracture
site. It is important to realise that the amount of motion tolerat- b
ed depends on the type of fixation that has been chosen. Two types of nonunion. a The hypertrophic
Two types of non unions can be differentiated: the hypertrophic nonunion has an elephant's foot appearance and
is well-vascularised. b The atrophic nonunion
and the atrophic types. In the first type, the ends of the bone are shows no reaction, eventually resorbtion of the
hypervascular and capable of biological reaction. Radiological- bone ends leads to true defects.
ly, this type can be recognised by its typical "elephant foot" ap-
pearance. In the second type, the bone ends are avascular and
characterised by the lack of callus and by a varying degree of re-
sorbtion. Either type of nonunion can be infected or noninfect-
ed. Treatment is directed towards improvement of the biologi-
cal and mechanical environment.
In hypertrophic nonunion, improvement of the biological po-
tential is superfluous. Improving the degree of stability is all that
is needed. This can be achieved by compression plating or in-
tramedullary nailing taking care to avoid additional devascular-
isation due to surgery. In the atrophic type, improvement of the
biological potential is necessary. This can usually be achieved by
decortication and cancellous bone grafting. Decortication in-
cludes resection of dead bone in the proximity of the nonunion.
C'
~ In the case of major defects, reconstruction can be achieved
=e.'l either by segmental bone transport or, for more substantial
ri:J
defects, by microvascular free bone transplantation.
The infected nonunion is a major challenge. As a general rule
infection has to be treated first by adequate debridement. Re- Compression plating of hypertrophic nonunion.
section of all necrotic tissue is mandatory. Resection of all in- Position of the plate is chosen according to the re-
quirements for axial correction. The plate is first
fected tissue including the bone is desirable but sometimes not
fixed to one fragment, then the articulating ten-
feasible. This is especially true for chronic infection where the sion device is mounted. Compression is applied
entire bone may be involved. Debridement and reconstruction while reduction is forced with a Verbrugge clamp .
• 542
are carried out in either one or several stages, depending on the
activity and extent of the infection. Reconstruction is per-
formed according to the same principles as above.
Prophylaxis should focus on active prevention of infection by
early debridement and soft tissue reconstruction in open frac-
tures and by choosing an adequate, nondevascularising fixation
for each given fracture situation
8.1.3 Segmental Bone Defect
Segmental bone defects are true cylindrical gaps in meta- or dia-

physeal bone. They can vary in length from 1 em to more than 30
em. Generally, they result from fractures or tumours. It is ex-
tremely rare to "lose" a segment of bone as a direct conse-
quence of the accident; more often a defect occurs later in the
treatment of high energy open or closed trauma. Debridement
of necrotic and/or infected bone may lead to the segmental de-
fect.
At present there are available 4 techniques for segmental bone
reconstruction:
Segment transport for diaphyseal defects.The 1. Cancellous bone graft (autologous)
unilateral tube fix ator is provided with a threaded
bar on which a short tube slides, driven by a trans- 2. Segmental bone transport
port nut. After the osteotomy and a lag period of 3. Vascularised bone transplantation (autologous)
a few days, the transport is started. Transport is 4. Nonvascularised allograft.
carried out at a rate of 1 mm per day. Experimental work indicates that cancellous bone graft
wrapped with vascularised periosteum is rapidly remodelled to
cortical bone and could therefore be an interesting option in the
future.
Cancellous bone graft alone is indicated for smaller defects.
Probably 5-6 em is a reasonable limit for this method although
clear scientific data are missing.
Segmental bone transport is a fascinating concept which was
1 ' popularised by Ilizarov. The principle consists in creating an ad-
ditional osteotomy proximal or distal to the gap. With an exter-
nal fixation device the intermediate segment is slowly transport-
ed, with steps of 1 mm per day. One problem is poor circulation
of the transported segment which impairs bone regeneration
and healing at the "docking" site.
Vascularised bone transplantation is a very efficient method of
a c
reconstruction. The fibula, where a segment of up to 30 em can
Vascularised bone transplantation. a Large seg- be harvested, is the main donor site. For femur and tibia recon-
mental defect, where segmental transport is not struction two parallel fibulae and additional cancellous bone
-
possible. b First step: the contralateral vascu-
graft are used. With this method full weight-bearing is generally
larised fibula is transplanted. Excentrical stable
possible at 6 months, independent of the length of the defect.
.:=
fixation is essential for early union of the os-
teotomies. c Second step: 2 months later the vas- Problems are related to the feasibility and patency of the mi- =
e
=
-.::=
cularised ipsilateral fibula is shifted medially, thus
crovascular anastomoses.
Ieconstructing the lateral cortex. The gap be- I
tween the two fibulae is filled with autologous Allograft is contraindicated in the post-traumatic situation due
"0'
bone graft. to its high infection rate. After tumour resection it is a valuable =-
543 •
alternative, especially when combined with a joint prosthesis.
Prevention of the defects emphasizes the avoidance of infection
in the early post trauma period. The key is primary debridement
and stable soft tissue coverage.
8.2 Degenerative and Metabolic Diseases
8.2.1 Osteoarthritis
Primary osteoarthritis is a degenerative joint disease which re-

sults mainly from mechanical wear of articular cartilage. It is
age-related and affects mainly, though not exclusively, the
weight-bearing extremities. The hip and the knee are most af-
fected and are a major cause of invalidity in the civilised coun-
tries. Surgical treatment ranges from osteotomy, arthrodesis, re-
section arthroplasty to partial or total joint replacement. In the
early stages more conservative techniques are indicated. A
good example is the proximal tibia osteotomy for varus goo- Chopard and subtalar arthrodesis. After resec-
arthrosis. By realignment of the axis, load is transferred from tion of the cartilage and partially of the subchon-
dral bone plate, the bones are placed in the de-
the medial to the relatively intact lateral compartment. sired alignement and stabilized with cancellous
Arthrodesis finds its area of indication mainly in the distal ex- lag screws.
tremities where other joints can partially compensate for the
loss of function. Typical examples are the subtalar arthrodesis,
ankle arthrodesis, wrist and first carpo-metacarpal arthrodesis.
Resection arthroplasties for osteoarthritis are reserved for the
small joints such as the acromio-clavicular joint or the first
metatarsophalangeal joint. Total joint replacement has proven
valuable for hip, knee, shoulder and elbow. Smaller joints are
also available but have a higher complication rate, especially in
osteoarthritis. To date, the lifetime of the prostheses is still limit-
ed to a decade or less.
8.2.2 Chronic Polyarthritis
it>
rLJ
Chronic polyarthritis is an inflammatory joint disease where
proliferation of the synovial membrane, possibly induced by au-
toimmune mechanisms against joint cartilage, progressively
~ destroys the joint. Due to ligamentous destruction, instability is
~ a main feature in the early stages, whereas gross articular de-
- struction follows at a later stage. Early synovectomy can delay
0~ the natural course of the disease and is especially indicated for Panarthrodesis of the hindfoot and ancle. When
Col
~ peripheral joints and tendon sheaths. Its aim is to prevent pro- screw fixation is contraindicated or not possible
(Infection, extremely soft bone) an external fixa-
gressive destruction and tendon ruptures. Depending on the tor can be used to obtain compression trough the
site, treatment options in the advanced stage are arthrodesis or main osteotomy planes.
• 544
total joint replacement. Total joint replacement is indicated for
all major joints, and for metacarpophalangeal and proximal in-
terphalangeal joints. Arthrodeses are functional for foot and
hand realignment. Due to the poor mineral content of rheuma-
toid bone, fixation techniques need to be adapted. A combina-
tion of Kirschner wires and tension band cerclages is the most
effective method of stabilisation. As an alternative, external fix-
ation with compression of the osteotomy site is especially valu-
able. Screws can be used for special indications (subtalar or
ankle fusion) although they might have insufficient purchase.
Additional cast immobilisation is often necessary.
8.2.3 Avascular Necrosis
a
Avascular necrosis is a localised disease of epiphyseal cancel-
lous bone. It is a disturbed vascular supply that leads to partial
or total necrosis of the subchondral cancellous bone. Mechani-
cal failure of the necrotic bone will eventually lead to fracture of
the subchondral bone plate which will affect the joint congruity.
D epending on the degree of deformity this will sooner or later
destroy the joint. The reasons for the impaired blood supply are
either traumatic (e. g. after a femoral neck fracture) or metabol-
ic (e. g. chronic alcoholism, immunosuppression, caisson dis-
ease, or sickle cell anaemia).
A typical treatment of partial femoral head necrosis before on-
set of degenerative joint changes is intertrochanteric flexion -
varisation osteotomy. The rationale of this operation is the un-
loading of the affected segment of the articulating head by ro-
tating it away from the main weight-bearing area, thus prevent-
ing further damage.
8.3 Tumours
8.3.1 Benign and Malignant Tumours

c
Intertrochanteric flexion-varisation osteotomy
for avascular necrosis of the femoral head. a The Although musculoskeletal tumours are relatively rare, their
necrotic volume is most frequently in the ante- early diagnosis is essential if recovery is to be achieved, especial-
rior-superior quadrant of the head (shaded area). ly for the most aggressive amongst them. The first sign is either
The purpose of the osteotomy is to unload the
diseased part of the head. b Osteotomy of the pain or a localised swelling. Conventional radiology will often
greater trochanter is followed by a vedge shaped show osteolytic or osteoblastic lesions. Fine details such as a
and a transverse intertrochanteric osteotomy. sclerotic rim around an osteolytic lesion, the changing of the
c With a 90° angled blade plate the desired
outer shape of the bone, or the type of periosteal reaction will
amount of correction is obtained through indirect
reduction. The incongruent osteotomy heals un- often help in further defining the type of lesion. Isotope scan,
eventfully. magnetic resonance imaging, computed tomography, and an-
545 •
giography help in further evaluation of anatomical and biologi-
cal features of the tumour. Finally, biopsy is essential for defini-
tive diagnosis.
The next step is the judgement of the degree of aggressiveness
of the tumour followed by multidisciplinary planning of treat-
ment. For malignant tumours, generally a resection in sound tis-
sue several centimetres away from the tumour gives a sufficient
margin. A variety of reconstruction techniques are possible,
taking advantage of all types of fixation methods. The fine
tuning between biology and mechanics remains the key factor
for successful reconstruction.
8.3.2 Metastatic Disease
Skeletal metastases are a frequent problem. Often they first

present with a spontaneous (pathological) fracture. These frac-
tures occur in the diseased bone without adequate trauma.
Metastases can be osteolytic or osteoblastic. Osteolytic metas-
tases are most often due to breast carcinoma, bronchus carcino-
ma, thyroid carcinoma or hypernephroma. Osteoblastic metas-
tases are mainly due to carcinoma of the prostate.
Treatment is mostly palliative. When pain is the presenting
symptom and skeletal weakening is not relevant, radiotherapy
is useful. If skeletal weakening is advanced so that an impending
fracture can be anticipated, prophylactic stabilisation with com-
posite fixation systems is indicated. When the bone has frac-
tured, intralesional tumour resection and stable composite fixa-
Composite fixation for pathologic fractures in
tion is aimed at. Composite fixation follows the known metastatic disease. After intralesional resection
principles of open reduction and internal fixation either with of the tumor, the fracture is stabilized with an in-
plates or i. m. nails. Methylmethacrylate is used to fill the de- ner and an outer plate. Push screws help main-
taining the correct position of the intramedullary
fects, giving primary, medium or long term stability to the com-
plate while the cavity is filled with pressurized
posite assembly. Adjunctive radiotherapy and /or chemothera- bone cement. The compound is immediatly stable
py is used. for full weight bearing.
8.4 Congenital Deformities
t'
~
Ef Congenital deformities are by definition already present at the
~ time of birth. Some are visible, other become apparent within
-e
~
.:: the first years of life.The aetiology is either genetic or due to
~J damage of the fetus during pregnancy, especially in the first 3
--; months when the fetus is particularly vulnerable to toxic agents.
=
8 This is the period when organogenesis takes place.
~ The most frequent localisations are the foot and the hip: about
~ 2 % of newborns have a clubfoot, while 1.5% show congenital
3 hip dislocation or dysplasia, although regional differences are
• 546
important. Treatment is primarily conservative. Corrective
splints, plasters or orthoses are often sufficient. In the advanced
stage surgical correction is necessary.
8.5 Glossary
Allograft: Tissue transplant (i.e. bone) from a donor of the same species
but genetically different. Bone is generally transplanted without revas-
cularisation. Histocompatibility studies, as in organ transplantation, are
not necessary.
Anastomosis: The anastomosis is the junction between two vessels or tubu-
lar structures.
Arthrodesis: Fusion of a joint that was obtained with a surgical procedure.
Ankylosis: Fusion of a joint that occurred spontaneously in the course of a
disease.
Biopsy: Excision of tissue, and histological examination to clarify the diag-
nosis.
Bone Graft: Cortical or cancellous volume of tissue used to reconstruct
areas of missing bone.
Buttress. A buttress plate supports the overlying bone.
Callus: During usual fracture healing callus is formed to bridge the defect.
It is a calcifying tissue that arises from fracture haematoma and pe-
riosteal tissue.
Chemotherapy: Treatment of malignant tumours with intravenous drugs to
impair or stop their growth.
Corticotomy: Special osteotomy where the medullary content and the pe-
riosteum is not injured while the cortical bone is cut with a chisel.
Debridement: Resection of all avascular tissue.
Deformity: Any anomaly in shape ofthe locomotor system.
Delayed union: Fracture that does not consolidate after 6 months.
Fibrocartilage: Repair tissue after lesion of the articular cartilage.
Malunion: Consolidation of a fracture in a bad position.
Methylmethacrylate: Polymer generally named bone cement.
Microvascular: Microvascular anastomoses or microvascular tissue trans-
fer is related to the need for an operating microscope to technically do
the anastomosis.
Nonunion: Lack of consolidation 9 months after the injury.
Osteoblastic: Producing bone.
Osteolytic: Resorbing bone.
Osteotomy: Controlled fracture of a bone.
Radiotherapy: Treatment of malignant tumours with X-rays.
Reduction: Achieve realignment of a displaced fracture.
Spontaneous Fracture: Fracture that occurs without an adequate trauma.
Synovectomy: Excision ofthe synovial membrane.
8.6 Recommended Reading
Brunner CF, Weber BG (1981) Besondere Osteosynthesetechniken.

Mast J, Jakob R, Ganz (1989) Planning and reduction techniques in frac-
Muller ME, All gower M, Schneider M, Willenegger H (1990) Manual of in-
ternal fixation, Springer, Berlin Heidelberg New York
Weber BG, Cech 0 (1973) Pseudarthrosen. Pathophysiologie-Bio-
mechanik-Therapie-Ergebnisse. Huber, Bern
547
•
9 Surgical Fixation
of the Immature Skeleton
By C. Colton
9.1 Anatomy of Growth
Long bones grow at the cartilaginous growth plates (or physes ).

These are discs of highly specialised cartilage tissue interposed
between the bone ends, or epiphyses, and the shaft of the bone.
The portion of the shaft near the physis is called the metaphysis,
the main shaft being the diaphysis. The layer of cartilage nearest
the epiphysis is nourished by blood vessels which loop down into
it from the epiphyseal circulation, and consists of small chondro-
cytes which gradually increase in number by cell division.
Epiphysis
Genninal zone ]
Proliferating layer growth plate
Hypertrophoc layer
Metaphysis
Metaphyseal vascular
Cortex supply
These "parent" chondrocytes form the germinal layer of the

physis, and the layer produced by their progeny is the layer or
zone of proliferation. After the new cells are produced they
start to swell, or hypertrophy, and at the same time line them-
selves up in columns parallel to the long axis of the bone; it is the
increase in diameter of these cells which thickens the growth
plate and causes the increase in length. As newer cells continue
to be formed by the germinal layer, the older cells in the meta-
physeal region of the growth plate, arranged in axial columns,
are separated by cylinders of cartilaginous matrix and each cell
lies in its own "pocket", or lacuna.
549
•
It is in the walls of these cylinders that calcification occurs.ln the ~~~~~~~~~Germinal zone
more mature layers of the growth plate the old hypertrophied Proliferation
cells die (as fine capillary loops from the metaphyseal circula-
tion enter there lacunae) and the cylindrical walls of calcified
matrix become covered with new bone, forming primary trabec-
Provisional o sification
ulae; this is the zone of provisional ossification. These primary
trabeculae are then remodelled in the metaphyseal zone to form
the normal trabeculae of cancellous bone. Cortical bone is laid
down by the periosteum.
9.2 Growth Plate Injuries
The intact growth plate resists axial loads well, provided the
membrane bounding the circumference of the cartilaginous disc
is intact. The growth plate is, however, less resistant to shearing
forces generated either by lateral shift or rotational displace-
ments. The zone of hypertrophy with its bulk of cytoplasm and
minimal matrix is the plane along which shearing forces disrupt
the physis. There are various patterns of growth plate injury, ac-
cording to the combinations of epiphyseal and/or metaphyseal
fracture that may accompany the growth plate disruption.
Salter Harris 5 types
-
~
=
=
~
..:.:
~
=
f::
Showing zone of shear and how this leaves the germinal and
~ proliferating layers with intact blood supply.
...~
-
-=
~
'C 9.3 Indications for Surgical Fixation
·=-
=
~
~
~ Most children's fractures require only conservative treatment.
'5 Fracture disease in the form of joint stiffness, marked muscle
·~ wasting, circulatory changes and lymphoedema are not promi-
~= nent features. Union of fractures is rapid and almost certainly as-
• 550
sured. The speed with which union occurs is, however, a limiting
factor on the time available to make management decisions- if
union is rapid, then malunion will be rapid! Although malunion
of a growing bone will remodel in many instances, if the deformi-
ty is not in the plane of motion of the nearest joint and/or the
child is near to skeletal maturity, remodelling is less likely.
Noncorrectable displacement may require surgical interven-
tion, but no precise indications can be given; it is a matter for ex-
perienced clinical judgement. Some growth plate injuries, espe-
cially those involving the joint surface (Salter Harris types 3 and
4), will need to be surgically fixed if they are displaced. Any such
fixation should avoid further violation of the growth cartilage-
implants are usually placed either totally intra-epiphyseally
and/or totally within the metaphysis The use of small cannulat-
ed screws for this purpose is most helpful. Very occasionally, the
bony fragments are too small for screws and Kirschner wires
have to be used, although much less secure fixation is afforded
and supplementary external splintage will be needed.
If plates are used on growing bones, it has to be remembered
that plastic deformation of the bone of a child is possible and
less compression can be applied than in adult bone. Also, be-
cause the growing bone is highly vascular, and therefore more
porous than adult bone, less screw torque can be applied. Con-
siderable surgical experience is required to avoid damaging the
bone. Intramedullary nailing is of limited application in the
child as it is virtually impossible to insert the nail without risking
significant damage to the growth plates. In general terms, the
sort of situations where surgical fixation is indicated are as
follows :
- Uncontrollable displacement of the fracture fragments due
to the nature of the fracture or the nature of the patient (head
injury, cerebral palsy, noncompliance for other reasons)
- Displaced physeal injuries, especially involving the joint sur-
face
- Fractures with major vascular compromise
- Multiple fractures in the polytraumatised child
- Severe open fractures, or fractures with adjacent severe soft
tissue injury
- Precision osteotomy in reconstructive and orthopaedic
surgery
- Certain specific injuries, including:
Unstable Monteggia injuries
Unstable pelvic injuries
Fractures of the femoral neck
Traumatic separation of the upper femoral epiphysis
Displaced tibial spine avulsions
551 •
9.4 External Fixation
External fixation is useful in children in certain situations. It is
rapid and reliable in the polytraumatised child. The "floating
knee" can be managed with minimal internal fixation, protected
for a short period by a femoro-tibial external fix a tor. Severe open
injuries are a strong indication for external fixation The tech-
niques of external fixation in the child do not differ from those
used in the adult, other than the need to respect the growth plate.
Union, as stated above, is usually rapid and rarely delayed in chil-
dren and the fixator can, in most cases, be removed fairly early.
9.5 Glossary
Avulsion: Pulling off
Chondrocytes: These are the active cells of all cartilage, whether articular
cartilage, growth cartilage, fibrocartilage, etc. They produce the carti-
lage matrix, both its collagen and the mucopolysaccharides of the ground
substance.
Cytoplasm: The substance of a cell that surrounds its nucleus.
Floating Knee: Fractures of the femur and the tibia in the same limb, result-
ing in the isolation of the knee joint from the rest of the skeleton.
Lymphoedema: Accumulation of watery fluid in the tissues as a result of
poor outflow of the lymph, usually due to the incompetence or obstruc-
tion of the lymphatic vessels.
Matrix: The relatively amorphous substance between the cartilage cells. It
consists of a network of collagen fibres interspersed with a "jelly" of wa-
terlogged mucopolysaccharide molecules (complex organic chemicals in
large molecular chains).
Monteggia Injury: A displaced ulnar fracture associated with a dislocation
of the radial head from its articulation with the capitellum. First de-
scribed in the nineteenth century by Giovanni Battista Monteggia, an
Italian physician.
Periosteum: The periosteum is the membrane covering the exterior surface
of a bone. The periosteum plays an active part in the blood supply to
bone, and bone remodelling:
Plastic Deformation: Change in the shape of a growing bone following the
application of a deforming force. The alteration in shape does not "re-
bound" to the original as the bone has been stressed beyond its elastic
limit, but not to the point of breaking. This usually only occurs in young
bones.
Polytrauma: Multiple injury. An injury severity score (ISS) of more than 16
is usually taken to indicate polytrauma.
Shear: Shearing forces are those which tend to cause one segment of a body
to slide upon another, as opposed to tensile forces which tend to elongate
or shorten a body.
Tibial Spine: The area of the proximal tibia lying between the medial and
lateral tibial plateaux, which is non-articular and bears the attachments
of the horns of the two menisci as well as the tibial ends of the two cru-
ciate ligaments.
Trabecula: The solid bony struts of cancellous bone.
9.6 Recommended Reading

Rang M ( ed) (1983) Children's fractures, 2nd edn. Lippincott, Philadelphia
Weber BG, Brunner C, Freuler F (1980) Treatment of fractures in children
and adolescents. Springer, Berlin Heidelberg New York
• 552
10 Infections After Surgical Fixation
By C. Colton
Infection of bone is a serious complication. It may occur by

blood-borne inoculation of hitherto healthy bone as haem-
atogenous osteomyelitis, which is usually a disease of children
and not within the scope of this discussion. In the adult, bone in-
fection usually follows either open fracture or occurs as a com-
plication of osteosynthesis. With good surgical care, the infec-
tion rates in each of these situations are low. In osteosynthesis of
closed fractures, the avoidance of infection relies upon many
factors, including:
- Immaculate aseptic procedures by the operating room (OR)
staff and surgical team
- A traumatic soft tissue handling
- Good OR discipline
- The preservation of the blood supply to the bone and the soft
tissues
- The achievement of fracture stability
- The timing of surgery
In osteosynthesis of open fractures, there is the added need for
careful surgical excision of any nonviable tissue from the injury
site and copious lavage. Infection of a fracture site results in the
death of tissue locally, including bone. Bone with marginal vas-
cularity is especially susceptible. High-energy injuries, where
the tissues are already severely compromised, suffer most if in-
fection supervenes.
Infection is to be suspected if the postoperative pain is more
than expected or increases, if the wound area is swollen and un-
expectedly tender, or if there is reddening of the skin and/or a
rising temperature. Once infection is seriously suspected, the
treatment is surgical. "Wait and see" results in progressive tis-
sue death and a worsening of the complication. Early infection
demands re-exploration of the fracture site. If there is any dead
and infected tissue, it must be removed, even bone. There is a
surgical maxim that all dead and infected bone end up in a buck-
et, one way or another! This may occur by deliberate debride-
ment, dismemberment or death. The former is desirable, the
others disastrous.
The surgically debrided site is then washed thoroughly with co-
pious volumes of fluid, preferably Hartmann's solution or
Ringer-lactate- dilution is the solution to pollution. A local an-
553
•
tibacterial agent must be delivered to the site of the infection, ei-
ther by irrigation-suction or by the implantation of a bacterici-
dal preparation, such as antibiotic impregnated polymethyl
methacrylate (PMMA) beads. Appropriate systemic antibiotic
therapy should be instituted, on the basis of the results from mi-
crobiological studies. Early exploration of the infection site
yields fluid and tissue for rapid identification of the organism.
The fracture should be stable. If the current implant continues
to control the fracture then it should not be removed. If on the
other hand, the implant is loose, then the fracture must be resta-
bilised by substitute internal fixation, or an alternative such as
external fixation. Once the infection is under control, any soft
tissue reconstruction procedures must be undertaken and vari-
ous techniques, including split skin grafting, local fascio-cuta-
neous or muscle flaps, or free microvascular tissue transfer, are
used in different situations.
The final stage of combating the effects of the infected os-
teosynthesis, when the infection is controlled and the soft tissue
envelope restored, is to proceed to bony union either by closed
cancellous bone grafting, open cancellous bone grafting (Pap-
ineau technique) or by bone transport techniques.
10.1 Glossary
Antibiotic: Any of various substances, such as penicillin, produced by cer-

tain fungi, bacteria, and other organisms, that are effective in inhibiting
the growth of, or destroying, microorganisms. They are widely used in
the prevention and treatment of infections.
Bactericidal: Capable of killing bacteria.
Haematogenous: Blood-borne.
Inoculation: The instillation, either by accident, or design, of micro-organ-
isms into the tissues or a culture medium.
Osteomyelitis: An acute or chronic inflammatory condition affecting bone
and its medullary cavity, usually in relation to bone infection.
-
.9=
~
I'll
~
";
..=
~
"Sil
..
r.l)
Q,j
0:::::
<
-
"'
.9=
~
~
=
....
• 554
Subject Index
Abduction 6 - DHS 136 Bactericidal 554

Absolute stability 23 Angled blade plate 130° 152 Ball spike, straight 220
Acetabuluar fractures 483 - application technique 167 Barrel 137
- anatomy 483 - instruments for application andre- Barton fracture, reversed 467
- AO classification 484 moval 173 Bending (twisting) irons 70
- assessment 483 - instruments for insertion andre- Bending iron
- checklist for operative technique moval 174, 176 - for Kirschner wires 182, 234, 364
486 - T profile 158 - for reconstruction plates, 2.7 mm-
- implant removal 487 - U profile 157 3.5mm 85
- indication, implant of choice 485 Angled piece - for small plates, 2.7 mm- 3.5 mm
- postoperative care 487 - large 345 236
- preoperative planning, preparation - small 345 Bending pliers 69
485 Ankylosis 547 -for reconstruction plates, 2.7 mm-
- special consideration 487 Anodised aluminium 398 3.5 mm 185, 219
Adaptation plate, 2.0 mm 247 Anodizied 51 Bending press 69
- instruments for application andre- Anterior 5, 6 Bending templates
moval 268, 270 Antibiotic 554 - for curved reconstruction plates,
Adduction 4 Antibiotic prophylaxis 45 3.5mm 219
Adjustable clamp 324 Antibody 31,32 - large 67,
Adjustable parallel wire guide, 124 Antigen 31,32 - for reconstruction plates, 2.7 mm-
Adult respiratory distress syndrome AO- Arbeitsgemeinschaft ftir Os- 3.5mm 185
37 teosynthesefragen 4 - for reconstruction plates, 4.5 mm
Aiming device 327,376 AO Classification 33 219
-for Unifix 349 AO/ ASIF Documentation centre - small 182
Aiming trocar 280 55 Bifurcated osteotomy plates 160
Air drill AO/ASIFFoundation 4 Biocompatibility 51
- small 383 AO/ ASIF instrumentation 49 Biological internal fixation 14, 20,23
- universal 387 AO/ ASIF screw thread 72 Biological osteosynthesis 18
Air hoses 382 AO/ASIFTechnical commission 49, Biopsy 547
Air jet for cleaning instruments 275 50 Blood supply,- to cortical bone 23
Air machines, cleaning and care 424 AO/ASIFtechnique 9 Bolt cutter 326
- lubrication 425 - aims 15 -cleaning and care 412
- packing and sterilisation 430 - biomechanical aspects 19 Bone
- rinsing and drying 425 Application diagram 374 - banking 31
Air tube, 2.0 mm 275 Arbeitsgemeinschaft ftir Osteosynthe- - defect 543
Allograft 30, 32,547 sefragen- AO 4 - forceps 358
- nonvascularised 543 ARDS 38 - formation 14
Aluminium 53 Arthrodesis 327,547 - graft 30, 547
- alloys 53 Arthrography 40 - - application 372
Aluminium cases 59 Articulated tension device 67 - - donor sites 370
American Society for Testing Material Assessment - - instruments 369
49 - fracture care 35 - healing 11, 12, 13, 14,15
Anaerobic 46 - soft tissues 35 - hook
Anastomosis 547 ASTM 49 - - large 361,222
..=
Anatomical position 4 A traumatic soft tissue handling 15, - - medium 361 ~
~
Anatomy 5 553 - - small 361 "CC
Anchoring hooks 222 Autograft 31 - porosis 14 .....
Anchoring rings 222 Avascular necrosis 545 - segment transport 333, 543 ~
~
Angle guide Avulsion 552 - spreaders :E'

- DCS 137 Awl, small 273 - -small 186 =
rJJ
555
•
Bone spreaders - for 4.5 mm cannulated screws 124 Cleaning and care of implants 421
- -large 360 - for7.0mmscrew 116 - implant cases 422
Bracing, functional 41 Caps for tubes and rods 325 - labelling/packaging 423
Broad lengthening plates 93 Carbon fibre rod -new 423
Broad spectrum 46 - 4.0mm 341 - restocking 422
Butterfly fracture 10 -11mm324 - reuse 423
Buttress 18, 24,547 Carbon fibre-reinforced 54 Cleaning brush
Care and maintenance of instruments - 2.1 mm 117
394 - 1.75mm 126
Calibrated drill bits 217 - before and during surgery 395 - 1.35mm 132
Calibrated taps - following surgery 397 Cleaning of complex instruments 405
- for 3.5 mm cortex screws 218 Carriage 354 Cleaning of instruments
- for 4.5 mm cortex screws 218 Cartilaginous matrix 550 - manual 400
Callus 12, 24, 547 Caudad 5 - mechanical 398
Cancellous bone 24 Caudal 5,6 - ultrasonic 399
Cancellous bone graft 543 CCD 135 Cleaning stylet
Cancellous bone screw, 4.0 mm 187, Centring pin - 2.0mm 116
188 - for hollow reamer 374 - 1.6mm 125
- insertion technique 195 - 4mm 272,311 - 1.25 mm 131
- instruments for insertion andre- Centring sleeve Cleaning of trays, cases
moval 214,216 - long, for DHS/DCS 139 - aluminium 401,402
Cancellous bone screws, 6.5 mm 74, - short, forD HS/DCS 138 - graphic 401
225 Cephalad 5 - stainless steel 401
- insertion technique 81 Cerclage wire 22 Cloverleaf plate 193
- instruments for insertion andre- - coils 365 - application technique 212
moval 82 - with eye 364 - instruments for application andre-
Cannulated cutter, 11 mm 272, 311 - precut lengths 364 moval 216
Cannulated countersink, 2.4 mm tip Cerclage wires 246 Clubfoot 546
130 Check tube 377 Coarse filter 381
Cannulated drill bit Chemotherapy 547 - cleaning and care 430
- 2.7mm 129 Children's fracture 549 Cobra head plates 92
- 3.2mm 123 - fixation 550 Calles fracture 467,541
- 3.5mm 132, - indication 550 Collum-centre-diaphysis, angle 135
- 4.5 mm 114,125 Chisel Combination wrench, 11 mm 67,278,
Cannulated hexagonal screwdriver - blades 361 312,322,349
- large 116 - guide 154 Combination wrench, 7 mm 341
- for 4.5 mm cannulated screws, 125 - handle 361 Compartment syndrome 16,45
- small 131 - interchangeable 370 Complete articular fracture 24
Cannulated screw instruments, clean- - pelvic osteotomy 219 Complex fracture 24
ing and care 408 Chondrocytes 552 Composites 54
Cannulated screw measuring device Chrome-plated instruments 399 Compressed air filter
- 3.5mm 130 Clamp - cleaning and care 430
- 4.5mm 124 - 4.0 mm/2.5 mm 340 - coarse 381
- 7.0mm 115 - 4.0 mm/4.0 mm 340 - micro 381,
Cannulated screw system Clamp, pear-shaped hole, 4.0 mm Compressed air machines 380
- 3.5mm 129 340 Compressed air motor 390
- 4.5mm 122 Classification Compressed air
- 7.0mm 113 - AO 33 - central supply 381
Cannulated screw, 3.5 mm 132 - of fractures 33 - cylinders 380
- insertion technique 133 - of instrumentation 59 - filters 381
- instruments for insertion andre- - of soft tissue 35,36 Compression
moval 134 Clavicular fractures 440 - interfragmentary 22, 24, 26
Cannulated screw, 4.5 mm 126 - anatomy 440 - plate 24
- insertion technique 126 - AO classification 440 - screw 24
- instruments for insertion andre- - assessment 440 - static 10
moval 128 - checklist for operative technique Compression plating 20, 24, 542
Cannulated screw, 7.0mm 117 441 Compression screw, DHS/DCS 140
- insertion technique 117 - implant removal 442 Condylar buttress plates 92,
- instruments for insertion andre- - indication, implant of choice 441 - application technique 109
moval 121, 122 - postoperative care 442 - instruments for application 112
Cannulated socket wrench, 11 mm 278 - preoperative planning, preparation Condylar plate, 95°, T profile 157
Cannulated tap 441 - instruments for insertion andre-
- for 3.5 mm cannulated screws 131 - special consideration 442 moval 174, 176
• 556
Condylar plate, 95°, U profile 156 - short 138 - of implants and instruments 57
- application technique 161,164 Cranial 5,6 - LC-DCP 87
- instruments for application andre- Creeping substitution 32 - taps 65
moval 172, 176 Cruciform screwdriver shaft 232 DHS 135
Condylar plate, mini, 1.5 mm 245 CT imaging 39 DHS locking device 142
- application technique 266 Curved aiming attachment 355 DHS plate 141
- instruments for application andre- Curved driving piece 278 - application technique 143
moval 269, 270 Cytoplasm 553 - instruments for application andre-
Condylar plate, mini, 2.0 mm 244 moval 150,151
- application technique 264 DHS trochanter stabilising plate
- instruments for application andre- Damaged screws 142
moval 268, 270 - instruments for removal 372 DHS/DCS direct measuring device
Condylar plate, small, 2. 7 mm 243 - technique 375 137
- application technique 260 DCP 19 D HS/DCS screw 140
- instruments for application andre- DCP drill guide DHS/DCS tap 138
moval 267,270 - 2.0mm 235 Diaphysis 25, 550
Condylar plate guide 153 - 2.7mm 235 Dimensional incompatibility 55
Conical extraction screws 372 - 3.5mm 179 Direct healing 25,
Connecting bar - 4.5mm 63,84 Direction finder 280
- 4mm 341 DCP hip drill guide, 4.5 mm 155 Disinfection,
- 5mm 324 DCP, 2.0 mm 247 - chemical 398
Connecting bolt 312 - application technique 265 - of implants 344
Connector - instruments for application andre- - ofinstruments 397,398
- for extraction hooks 282 moval 268, 270 - thermal 398
Conservative treatment 41 DCP,2.7mm 246 Dismantling of instruments 397
Contact healing 24 - application technique 260 Distal 5, 6
Contaminated instruments 397 - instruments for application andre- Distal aiming device 281
Contouring of plates 110 moval 267,270 Distractor, large 352
Core diameter 73 DCP,3.5mm 191 - application technique 355
Coronal 5,6 - application technique 202, 203,206, - instruments 353,357
Corrosion, causes 394 207 Distractor, small 357, 185
Corrosion resistance 52, 53 - instruments for application andre- Dorsal 5,6
Cortex screw, 1.5 mm 240 moval 215,216 Double air hose
- insertion technique 253,256 DCP, 4.5 mm 84, 86, 87, 227 - large 382,
- instruments for insertion andre- - application technique 94, 96, 97, - small 392
moval 269,270 100,101, Double drill sleeve
Cortex screw, 2.0 mm 240 - instruments for application 112 - 1.5 mm/1.1 mm 231
- insertion technique 251, 253 DCS 135 - 2.0 mm/1.5 mm 231
- instruments for insertion andre- DCS plate 142 - 2.7 mm/1.25 mm 129
moval 268, 270 - application technique 146,150 - 2.7 mm/2.0 mm 228, 339
Cortex screw, 2.7 mm 239 - instruments for application andre- - 3.5 mm/2.5 mm 130, 179
- insertion technique 249,251 moval 150, 151 - 4.5 mm/3.2 mm 62,115,124
- instruments for insertion andre- Debricolage 25 - 6.5 mm/3.2 mm 63
moval 267,270 Debridement 16, 17,18,43,547,553 Drill bit
Cortex screws, 3.5 mm 188, 225 Decortication 542 - 1.1 mm 230,
- insertion technique 196,197 Deformity 547 - 1.5mm 123,230
- instruments for insertion andre- - congenital 546 - 2.0mm 114,136,153,184,227,
moval 215,216 - post-traumatic 541 339,362
Cortex screws, 4.5 mm 73, 225 Delayed union 542, 547 - 2.5 mm 177, 184
- insertion technique 77 Depression - 2.7mm 228
- instruments for insertion andre- - split 28 - 3.2mm 61,280,346
moval 82 Depth gauge - 4.0 mm/4.5 mm 180
Cortical bone 9, 25 - 1.5 mm- 2.0 mm 230, - 3.5 mm 217, 177,184,321,346,353,
Corticotomy 547 - 2.7mm-4.0mm 228 355
Countersink - 3.5mm-4.0mm 178,184 - 4.5mm 217,281,321,349
- large 64 - 4.5 mm- 6.5 mm 64 - 4.5 mm, for Jacobs chuck 349
- mini, 1.5 mm/2.0 mm 230 - combined, for 3.5 mm- 6.5 mm - 5.0 mm, high-speed steel 375
~
- small, 2.7 mm 228 screws 220 Drill bits
-=
-=
~
Coupling block - for locking bolts 281 - calibrated 61, 62,

- with round sleeve 312 - for Schanz screws 322 - four-fluted 61 ....
~
- with square sleeve 312 Design - for mini compressed air machine ~
Coupling screw - DCP 85 392 :2

- long 139 drill bits 60 - three-fluted 61 =
riJ
557
•
Drill guide with stop - instruments 338 Foot fractures 533
- 3.5 mm/2.7 mm 130 - instruments for removal 343 - anatomy 533
- 4.5 mm/3.2 mm 68 Extra-articular fracture 25 - AO classification 534
Drill head attachments Extraction bolts 373 - assessment 533
- straight 391 Extraction hooks, for nails 283 - checklist for operative technique
- 45°, for Kirschner wires 391 537
- 90° 391 - implant removal 539
Drill sleeve 105 mm Far cortex 25 - indication, implant of choice 534
- 5.0 mm/3.5 mm 322,353 Fascia-cutaneous 46 - postoperative care 538
- 6.0 mm/3.5 mm 346 Fasciotomy 46 - preoperative planning, preparation
- 6.0 mm/5.0 mm 322, 353 Femoral shaft fractures 494 535
Drill sleeve 135 mm - anatomy 494 - special consideration 538
- 5.0 mm/3.5 mm 355 - AO classification 495 Force
- 6.0 mm/5.0 mm 355 - assessment 495 - bending 10
Drill sleeve 75 mm - checklist for operative technique - tensile 10
- 5.0 mm/3.5 mm 322 497 Forceps for screw removal 374
- 6.0 mm/5.0 mm 353 - implant removal 499 Four-fluted drill bits 125,129, 132
Drill sleeve, 60 mm - indication, implant of choice 496 Fracture 25
- 4.0 mm/3.5 mm 346 - postoperative care 499 - disease 25
Drill sleeve, for nailing - preoperative planning, preparation - healing 19
- 8.0mm/3.2mm 313 497 Frontal 5,6
- 8.0 mm/4.5 mm 281 - special consideration 498
Drill sleeve, for U nifix, 6.0 mm/4.5 mm Femur fractures, distal 500
349 - anatomy 500 Galeazzi fracture 466
Drill sleeves for aiming device 379 - AO classification 501 Gap healing 25
Driving head 279 - assessment 501 Germinallayer 550
Drying - checklist for operative technique Gliding hole 20, 25
- ofimplants 422 503 Gliding splint 26
- ofinstrunents 402 - implant removal 505 Goal of fracture treatment 26
Dynamic compression plate 20 - indication, implant of choice 501 Gouge
- 3.5 mm 191 - postoperative care 505 - hollow 373
- 4.5mm 84 - preoperative planning, preparation - interchangeable 370
Dynamic condylar screw 135 502 Graphic cases 59
Dynamic hip screw 135 - special consideration 504, Growth plate 549
Dynamisation 25 Femur fractures, proximal 488 - injuries 550
- of external fixator 333 - anatomy 488 Guide handle, for nails 282
- of universal nails 306 - AO classification 489 Guide pin, 2.5 mm,- DHS/DCS
- ofUTN 319 - assessment 489 136
Dysplasia 546 - checklist for operative technique Guide rod retainer 279
Dystrophy 12, 13 491 Guide rod
- implant removal 493 - 3mm 276
- indication, implant of choice 489 - 4mm 276
Electropolishing 50 - postoperative care 493 Guide shaft 138
Elephant foot 542 - preoperative planning, preparation Guide wire, threaded
Endosteal 46 491 - 1.25mm 129
Energy transfer 46 - special consideration 492 - 1.6mm 123
Epiphysis 25,550 Fibrocartilage 547 - 2.0mm 114
Exhaust diffusor 383 Figure-of-eight wire 367
- cleaning and care 430 Fixation, absolutely stable 22
Extensor 6 - biological 14 H plate,1.5 mm 248
External casting 42 - flexible 23 - application technique 266
External fixation 18, 21,44 - rigid but not absolutely stable 23 - instruments for application andre-
External fixation devices 320 Fixation bolt moval 269,270
- cleaning and care 409 - femoral 281 H plate, 2.0 mm 248
External fixation, various fractures - tibial281 - application technique 266
435 Flexible fixation 23, 25 - instruments for application andre-
External fixator, large Flexible grip 279 moval 268, 270
- application 329,331,333,335 Flexible shaft Haematogenous 554
- consideration, when applying 328 - cleaning and care 406 Hammer
- instruments for application andre- - front cutting 274 - lOOg 238
moval 321,336,337 - 8mm 274,-lOmm 274 - 300g 361
External fixator, small Flexor 6 - 500g 361
- application technique 342 Floating knee 552 - 700g 361
• 558
Hand drill 393 - anatomy 447 - for angled blade plates 155
- accessoires 393 - AO classification 448 - cleaning and care 407
Hand, fractures 471 - assessment 448 - small 156
- anatomy 471 - checklist for operative technique - forUTN 313
- AO classification 471 449 Insertion handle
- assessment 471 - implant removal 450 - for universal nails 277
- checklist for operative technique - indication, implant of choice 448 - forUTN 312
473 - postoperative care 450 - for UTN 45° 312
- implant removal 475 - preoperative planning, preparation Integument 35,36
- indication, implant of choice 472 448 Interchangeable gouges, chisels and
- postoperative care 475 - special consideration 450 impactors 366
- preoperative planning, preparation Humerus fractures, distal 451 Interfragmentary compression 22, 24,
473 - anatomy 451 26
- special consideration 475 - AO classification 451 Interlocking nail 26
Handle - assessment 451 Internal fixation 16, 20, 42
- with mini quick coupling 231,232 - checklist for operative technique Internal fixation, various fractures
- with quick coupling 130, 229 453 435
Hartmann's solution 43, 553 - implant removal 455 International Organisation for Stan-
Haversian system 26 - indication, implant of choice 452 dardisation 49
Healing, bone 26 - postoperative care 455 Intramedullary nailing 17, 21,44
Henry's approach 464 - preoperative planning, preparation Intramedullary nailing instruments
Hepatitis virus 31 452 271
Heterograft 32 - special consideration 454 - reaming instruments 271
Hexagonal Allen key Humerus fractures, proximal 443 - insertion instruments 276
- large 69,272 - anatomy 443 - lockinginstruments 279
- with pin 349 - AO classification 443 Ischaemia 46
- small 185 - assessment 443 ISS 37
Hexagonal pelvic screwdriver - checklist for operative technique
- large 218 445
- small 218 - implant removal 446 Jacobs chuck
Hexagonal pelvic screwdriver shaft - indication, implant of choice 444 - for small air drill 385
- large 218 - postoperative care 446 - for universal drill 388
- small 219 - preoperative planning, preparation
Hexagonal screwdriver 444
- large 66, 282 - special consideration 445 Kirschner wire attachment 45° 391
- mini 232 Hypovolaemia 46 Kirschner wires
- small 229 Hypoxia 46 - double trocar tip 366
- for3.9mmlockingbolts 313 - threaded tip 339, 365
Hexagonal screwdriver shaft - trocar tip 68,153, 193,246,339,365
- large 67, 125 Ilizarov 327, 543 Knurled nut 312
-mini 232 Imaging technique 38 Kocher-Langenbcck approach 486
- small 229 Immobilization 12
History of osteosynthesis 3 Immunology, bone grafting 30
HIV 31 Impacted fracture 26 L plate, small, 2.7 mm 242, 246
Holder 282 Impactor - application technique 259
Holding clip - for angled blade plates 135 - instruments for application andre-
- 2.0mm 235 - cancellous bone 367 moval 267,270
- 2.7mm 235 - DHS/DCS 139 Lacuna 549
- 3.5mm 181 - forked 378 Lag screw 22, 26
Holding forceps 273 - interchangeable 366 - technique 20,76
- for cerclage wires 363 Implants, cleaning and care 421 Large bone plates 83
- for small plates 238 Incompatible tolerances 56 - special 91
Hollow reamer 373 Indirect healing 26 - standard 84
Homograft 32 Infant hip plates 160 - straight 84
Hook - instruments for application andre- Large bone screws 71
- for external fixator 377 moval 175, 176 Large plate application technique
- large, for knee 377 Infection 553 94
- offset, pointed 378 Inferior 5, 6 Large screw insertion technique 76
- small, for knee 377 Injury severity score 37 Lateral 5,6
Horizontal 6 Insert drill sleeve Lateral tibial head plates 92
Hose connector 90° 391 - 3.5 mm/2.5 mm 179 - application technique 109
Human immunodeficiency virus 31 - 4.5 mm/3.2 mm 62, 281 - instruments for application 112
Humeral shaft fractures 447 Inserter- Extractor LC-DCP 19
559 •
LC-DCP drill guide Medullary nailing 17, 21,44 - assessment 456
- 3.5mm 180 Medullary reamers 274 - checklist for operative technique
- 4.5 mm 63, 88 - cleaning 406 458
LC-DCP universal drill guide Medullary tube 275 - implant removal 459
- 3.5mm 180 Metals - indication, implant of choice 457
- 4.5 mm 63, 89 - for implants 49 - postoperative care 459
LC-DCP,3.5mm 191 - for instruments 52 - preoperative planning, preparation
- application technique 208,210,211 Metaphysis 26, 550 457
- instruments for applicaction andre- Metastatic disease 546 - special consideration 459
moval 216 Methylmethacrylate 546,547 Oligotraumatic 15
LC-DCP, 4.5 mm 87, 89 Micro filter 381 One-third tubular plate 190
- application technique 102, 103, 106 - cleaning and care 430 - application technique 200, 201
- instruments for application 112 Microvascular 547 - instruments for insertion andre-
Leg lengthening 333 Midline 6 moval 216
Lengthening apparatus, large and Mini compressed air machine 390 Open clamp 325
small 345, - accessoires 391 - pear-shaped hole 340
- application technique 347 - burrs 392 - 4.0 mm/4.0 mm 340
- instruments 345 - circular saw 392 - 4.0 mm/2.5 mm 340
Lengthening apparatus, small 348 - cleaning and care 429 Open compressor
Limited contact- DCP 87 - drill bits 392 - large 325
Locking bolt Mini fragment plates 242 - small 341
- 3.9mm 314 Mini fragment screws 239 Open fractures
- 4.9mm 285 Mini oscillating saw 391 - treatment 43
Locking bolts 21 - saw blades 391 Operating room staff 57,435,553
Locking nut Mini plate, straight, 1.5 mm 244 Opposition 6
- for threaded rod, 14 mm 354 - application technique 266 Oscillating attachment 326, 386
- for universal nails 277, 278 - instruments for application andre- - cleaning and care 426
Locking pliers 275 moval 269,270 Oscillating bone saw 388
Locking sleeve, aiming device 376 Mini plate, straight, 2.0 mm 243, 247 - cleaning and care 428
Locking splint 26 - application technique 261 - operation 389
Lubrication - instruments for application andre- - saw blades 389
- of air machines 425 moval 268, 270 Osseo-fascial muscle compartment
- of instruments 403, 404 Mini quick coupling chuck 385 47
Lymphoedema 552 Mini reciprocating saw 392 Osteoarthritis 544
- saw blades 392 Osteoblast 27, 547
Mixing of instruments and implants Osteoclast 27
M.E.S.S 36 54 Osteoconduction 30
Magnetic Resonance Imaging 40, 50 Monteggia fracture 466,551,552 Osteogenesis 30
Malleolar fractures 527 MRI 40 Osteoinduction 30
- anatomy 527 Multifragmentary fracture 26, 46 Osteolytic 547
- AO classification 528 Osteomyelitis 554
- assessment 528 Osteon 26
- checklist for operative technique Narrow lengthening plates 93 Osteopenic 47
530 Nearcortex 26 Osteosynthesis 3, 47
- implant removal 532 Necrosis, 15, 18 Osteotome, small 238
- indication, implant of choice 529 - avascular 545 Osteotomy plates for adults, U profile
- postoperative care 532 Neutralisation 27 158
- preoperative planning, preparation - plate 20 - application technique 170
530 New implants, care of 423 - instruments for application andre-
- special consideration 531 New instruments, care of 415 moval 173, 176
Malleolarscrew 75 Nonunion 542,547 Osteotomy plates for children 159
Malunion 541,547 - atrophic 542 - instruments for application andre-
Mangled extremity severity score 36 - hypertrophic 542 moval 175, 176
Manipulation nail, 11 mm 355 - infected 542 Osteotomy plates for small adults and
Material Nut adolescents 159
- for implants 49, 56 - for 4.5 cortex screw 76 - instruments for insertion andre-
- for instruments 52 - 11mm 327 moval 175,176
- incompatibility 55 Overbending, of plate 27
Matrix 552
Measuring bar, aiming device 376 Oil, SYNTHES 403
Measuring gauge for nails 276 Olecranon fractures 456 Palmar 6
Measuringrod 311 - anatomy 456 Parallel drill guide 115
Medial 5,6 - AO classification 456 Parallel pliers, flat-nosed 363
• 560
Parallel wire guide 115 Plastic deformation 552 Radial head, fractures 460
- adjustable 124 Plate bending 111 - anatomy 460
Partial articular fracture 27 Plate bending forceps, mini fragment - AO classification 460
Passivation layer 394 plates 234 - assessment 460
Patella, fractures 506 Plate bending instruments 69 - checklist for operative technique
- anatomy 506 - cleaning and care 413 461
- AO classification 507 Plate cutting forceps 233 - implant removal 462
- assessment 506 Plate length and engaged cortices - indication, implant of choice 460
- checklist for operative technique 109 - postoperative care 462
508 Plating 44 - preoperative planning, preparation
- implant removal 509 PMMA 554 461
- indication, implant of choice 507 Polyarthritis, chronic 544 - special consideration 461
- postoperative care 509 Polymethyl-methacrylate beads 554 Radial preload 19,27
- preoperative planning, preparation Polytrauma 37, 47,552 Radiation shield 282
507 Positioning of cortex screws 77 Radiography 38
- special consideration 509 Positioning screw 197 Radiolucent drive 283, 386
Patellar forceps 359 Posterior 5, 6 - cleaning and care 427
Pelvic Power equipment, cleaning and care - drill bits 283,386
- implants 225 424 Radiotherapy 547
- osteotomy chisel 219 Power machines 380 Radius fractures, distal 467
- reduction forceps 220,221,222 - hand 393 - anatomy 467
- retractor, blunt 220 - mini 390 - AO classification 467
- special consideration 482 - oscillating 388 - assessment 467
Pelvic C-clamp 222 - small 383 - checklist for operative technique
- application technique 224 - universal 387 469
Pelvic fractures 476 Pre bending of plate 27 - implant removal 470
- anatomy 476 Precisce reduction 27 - indication, implant of choice 468
- AO classification 478 Preload 10, 22,27 - postoperative care 470
- assessment 476 - radial 27 - preoperative planning, preparation
- checklist for operative technique Pre loading Schanz screw 328 468
480 Pressure regulator, fine 382 - special consideration 470
- implant removal 482 - cleaning and care 430 Radius shaft fractures 463
- indication, implant of choice 478 Prestress 110 - anatomy 463
- postoperative care 482 Proliferating layer 550 - AO classification 464
- preoperative planning, preparation Pronation 6 - assessment 463
479 Prophylactive 47 - checklist for operative technique
Percutaneous sleeve assembly Protection 27 465
- 7.0mm 114 - plate 20 - implant removal 466
- 4.5mm 123, - sleeve - indication, implant of choice 464
Periosteal 47 - - for cannulated cutter 311 - postoperative care 466
Periosteal elevator 360 - - 11 mm/8mm 281,312 - preoperative planning, preparation
- for mini fragments 232 Protective caps, 4.5 mm and 5.0 mm 464
- for small fragments 184 328 - special consideration 466
Periosteum 14,552 Proximal 5, 6 Ram 279
Pilon fractures 523 Pseudarthrosis 542 Ram guide 279
- anatomy 523 Pure depression 27 Rasp, interchangeable 370
- AO classification 523 Pure split 27 Reamer
- assessment 523 Pure titanium 50 - hand 273
- checklist for operative technique - heads 274
525 - -cleaning 406
- implant removal 526 Quadrangular positioning plates - hollow 373
- indication, implant of choice 524 153 - medullary 274
- postoperative care 526 Quarter tubular plate 242 - tube for hollow reamer 37 4
- preoperative planning, preparation - application technique 256, 258 Reaming rod, 3 mm 273
524 - instruments for application andre- Reconstruction plate, 3.5 mm 194,
- special consideration 525 moval 267,270 225
Pilot hole 27 Quick coupling - application technique 213
Pin loosening 27 - for hand drill 393 - curved 226
Pin wrench 278 - for small air drill 139 - instruments for application andre-
Pin less fixator 343 - for universal air drill 139 moval 216
- application technique 344, Quick coupling, D HS/DCS reamer, Reconstruction plates, 4.5 mm 90, 226
- instruments 344 for small air drill 385 - application technique 107
Plantar 6 - for universal drill 387 - instruments for application 112
561 •
Reconstructive surgery 541 Screwdriver, see Hexagonal screw- Spherical gliding principle 84
Reduction 10, 17 driver Spiked disc 221
- direct surgical 11 Screw forceps 72, 116,125, 131, 181, Spiked washer
- external 10 234 - 8mm/3.2mm 190,241
- indirect surgical 11, 17, 18 Screw holding sleeve - 13.5mm 76
Reduction forceps - large 66,116,125,218,282,314 Splinting 21,28
- large bone 358, 359 - small 218,229 Split depression 28
- forsmallandminifragments 183, Screw holding sleeves, dis tractor 354 Spontaneous healing 28
185,233,236,237 Screwdriver Spoon plate 94
Refracture 28 - with T handle 68 Spring loaded nut 34
Relative stability 28 - with universal joint 68 Stability 12
Remodeling (of bone) 28 Seating chisel Stable fixation 28
Removal of nails 309 - small, T profile 155 Stag beetle forceps 233
Repair service 431 - T profile 155 Stainless steel 52
Resorption, bone 19, 28 - U profile 154, - austenitic 52
Retractor 360 Segmentalbonetransport 333,543 - martensitic 52
- malleable 237 Segmental fracture 47 - 316L 49
- for small and mini fragments 184, Self-centering bone holding forceps Standard instruments 60
232 - for large bones 359 Steinmann pin
Retrieved implants 432 - for small bones 183 - 4.5mm 327
Reversed Barton 467 Semitubular plates 90 - 5.0mm 327
Right-angle drive 388 - application technique 106 Sterilisation of instruments 414
Rigid fixation 28 - instruments for application 112 -methods 417,418,419
Rigid implant 28 Shaft diameter, screw 73 - packing material 417
Rigidity 28 Shaft screw, 3.5 mm 189 - preparation 416
Ring wrench, 11 mm/14mm 346 - insertion technique 198, 199 - storage 440
Ringer's lactate solution 43, 553 - instruments for insertion andre- - trays 59
Rinsing moval 215,216 Steriliser indicator 395
- of implants 422 Shaft screw, 4.5 mm 74 Stiffness
- ofinstruments 402 - insertion technique 80 - geometrical properties 28
Router, 7 mm 154 - instruments for insertion andre- - material properties 28
Rust transfer 395 moval 82 Strain 16, 28
Sharp hook 67,181,234,373 - induction 29
Shear 552 - tolerance 29
Safe corridor 329 Shot-peened 50 Strength 29
Sagittal 6 Simple fracture 28 - ofbone 9
- plane 5 Simple handle 326, 349 Stress
Saw blades Single air hose 382 - protection 29
- oscillating saw 389 Skeletal stabilisation 44 - shielding 29
- mini oscillating saw 391 Sleeve-holding bracket 354 Suction device, cleaning and care
- mini reciprocating saw 392 Slotted hammer 154,312 413
Scapula, shoulder joint, fractures Small air drill 383 Superior 5, 6
435 - accessories 385 Supination 6
- anatomy 436 - application 384 Surgical treatment of fractures 42
- AO classification 437 - cleaning and care 426 Suture passer 379
- assessment 437 Small countersink, 3.5 mm/4.0 mm - pusher 379
- checklist for operative technique 178 Synovectomy 547
438 Small fragment instruments 177 Systemic 47
- implant removal 439 Small fragment plates 190
- indication, implant of choice 437 Small fragment screws 187
- postoperative care 439 Small hexagonal screwdriver 181 T and L Buttress plates 91
- preoperative planning, preparation - shaft 131 - application technique 108
438 Smallscrewholdingsleeve 131,181 - instruments for application 112
- special consideration 439 Smith-Goyrand fracture 467 T handle, 64, 124, 179,373
Schanz screw insertion 329 Socket wrench 68, 323 - DHS/DCS 136
Schanz screw - 7mm 341 T plate, mini, 1.5 mm 245
-3.0 mm/4.0 mm 340 Soft tissue - application technique 266
- 4.0mm 346 - handling 14, 17 - instruments for application andre-
- 4.5mm 323 - mJury moval 269, 270
- 5.0 mm 323, 353, - -classification 35 T plate, mini, 2.0 mm 244, 248
- 6.0 mm 222, 346, 350 - surgery 43 - application technique 263
- 6.0 mm, roughened surface 350 Soudure auto gene 4 - instruments for application andre-
- radial preload 323 Spherical screw head 72 moval 268, 270
• 562
T plate, small 192, 193 - assessment 516 - implant removal 466
- application technique 212 - checklist for operative technique - indication, implant of choice 464
- instruments for application andre- 520 - postoperative care 466
moval 216 - implant removal 522 - preoperative planning, preparation
- instruments for application andre- - indication, implant of choice 517 464
moval 267,270 - postoperative care 522 - special consideration 466
T plate, small, 2.7 mm 242 - preoperative planning, preparation Ultrasound 40
- application technique 259 519 Unifix 348, 350,
Tplates 91 - special consideration 521 - application technique 350
- application technique 108 Tibial spine 552 - cleaning and care 411
- instruments for application 112 Tillaux-Chaput 523 - instruments 349
Tap Tissue protector 275 - removal 352
- for 1.5 mm cortex screws 231 Titanium alloys 51 Universal air drill, cleaning and care
- for 2.0 mm cortex screws 230 Tomography 39 427
- for 2. 7 mm cortex screws 228 Tool steel 53 Universal chuck
- for 3.5 mm cortex screws 178, 184 Toxins 47 - for hand drill 393
- for 4.0 mm cancellous bone screws Trabecula 156, 157,552 - for universal drill 388
178, 186 Traction 41 Universal chuck with T handle 222,
- for 4.5 mm cortex screw 65 Transfixation screw 197 272,311,323,346,353,366
- for 6.5 mm cancellous bone screw Transport nut 327 Universal drill 387
66 Transport tubes, 11 mm 327 - accessories 387
Telescoping wire guide 366, 386 Transverse 6 Universal femoral nail 284
Tension band principle 29 - plane 6 Universal femoral nailing 286
Tension band wiring technique 366 Transverse clamp 325 - determination of length and diame-
- instruments 369 Treatment, fractures ter 289
- olecranon 366 - conservative 41 - dynamisation 306
- patella 368 - open fractures 43 - insertion 291
Termite forceps 236 - soft tissue injury 43 - instruments for insertion, locking
Thermoplastics 54 - surgical 42 and removal 306, 307, 308
Thermosetting plastics 53 Triangular positioning plates 153 - locking 292,293, 294
Thread hole 27 Triple drill guide 154 - point of insertion 289
Threaded conical bolts Triple drill sleeve assembly - positioning 287
- for universal nails 277, 278 - 80mm 322 - reaming 288
- forUTN 312 - 110mm 321,353 - reduction 285,286
Threaded guide wire - 140mm 355 Universal joint for two tubes 325
- 1.25 mm 129 - small 339 Universal tibial nail 284
- 1.6mm 123 Triple reamer Universal tibial nailing 297
- 2.0mm 114 - cleaning and care 405 - determination oflength and diame-
Threaded rod - DCS 138 ter 298
- 8mm 326 - DHS 137 - dynamisation 306
- 14mm 354 - short 138 - insertion 300
Three-fluted drill bits 114,217,326, Triple wire guide, 2.0 mm 179, 235, - instruments for insertion, locking
379 339,362 and removal 307, 308
- with coupling for radiolucent drive Trocar - locking 302, 303, 304
283,313 - 60mm,3.2mm 346 - point of insertion 298
Thromboembolic complication 45 - 80 mm, 3.5 mm 322 - positioning 297
Tibia fractures, distal, see Pilon frac- - 110 mm, 3.5 mm 322, 346, 353, - reaming 299
tures 378 - reduction 297
Tibial plateau, fractures 510 - 140mm,3.5mm 355 Unreamed nailing 45
- anatomy 510 - for interlocking, 8 mm 281,312 - nails 17,21
- AO classification 511 - for Unifix, 4.5 mm 349 Unreamed tibial nail 310
- assessment 511 Tube-to-tube clamp 325 Unreamed tibial nailing 315
- checklist for operative technique Tubes, 11 mm, stainless steel 324 - determination of length and diame-
512 Tubular external fixator 321 ter 315
- implant removal 513 Tumors 545 - dynamisation 319
- indication, implant of choice 511 - instruments for insertion, locking
- postoperative care 514 andremoval 319,320
- preoperative planning, preparation Ulnar shaft fractures 463 - locking 317,318,319
512 - anatomy 463 - pointofinsertion 316
- special consideration 513 - AO classification 464 - positioning 315
Tibial shaft, fractures 515 - assessment 463 U nreamed tibial nailing instruments
- anatomy 516 - checklist for operative technique 311
- AOclassification 517 465 UTN 310,314
563 •
Valgus 6 - 10mm 126 Wrench, 8 mm 69
Varus 6 - 13mm 75,117 Wrench, DHS/DCS 138
Vascularised bone transplantation Washing machine 398 - combined 140
543 Wedge fracture 29
Vascularity 29 Wire bending pliers 182,234,363
Ventral 5 Wire cutter Xenograft 32
Vertical 6 - large 364
Vice grip, self-locking 363 - small 234, 364
Wire holding forceps, long 363
Wire Passer 362
Washer Wire tightener 362
- 4.5mm 241 - "Fastight" 363
- 7.0mm 132,189,241 Wiring instruments 362
• 564
M.E.Miiller, M.Allgower, R.Schneider, H. Willenegger
Manual of
Internal Fixation
Techniques Recommended by the AO-ASIF Group
Contribution on Biomechanics by S.M. Perren
Coordinating Editor: M. Allgower
3rd, exp. and completely rev. ed. 1991.
XXVIII, 750 pp. 500 figs. mostly in color.
ISBN 3-540-52523-8
The Manual of Internal Fixation is well known internationally as a

standard work for every specialist dealing with osteosynthesis. Every
year hundreds of courses are held for orthopedic surgeons all over the
world, so that they may learn the operating techniques according to the
AO principles.
Due to the many changes that have taken place in recent years, the
authors have completely revised and expanded the manual. This new,
third edition reflects today's knowledge and is the necessary reference
for every AO specialist.
Springer
Preisanderungen vorbehalten. B3.09. lll
M. E. Muller, S. Nazarian, P. Koch, J. Schatzker
The Comprehensi ve Classification of Fractures

of Long Bones
With the collaboration of U. Heim
1990. XIII, 201 pp. 93 figs., mostly in colour. ISBN 3-540-18165-2
This book presents a comprehensive classification of fractures of all long bones. The fundamental
principle of this classification is the division of all fractures of a bone segment into three types and
the further subdivision into three groups and their subgroups. The groups are arranged in an
ascending order of severity according to the morphologic complexities of the fractures, the diffi-
culties inherent in their treatment, and the prognosis. Thus once a surgeon classifies a fracture,
he will have determined its severity and will have a guide to its best possible treatment.
U. Heim, K. M. P{eiffer
Internal Fixation of Small Fractures

Technique Recommended by the ASIF-Group
3rd Edition of Small Fragment Set Manual
In Collaboration with J. Brennwald, C. Geel, R. P. Jakob, T. Riiedi, B. Simmen, H. U. Staubli
Translated from the German by T. C. Telger
Drawings by K. Oberli
1988. 258 figs. in more than 700 sep. ills. XI, 393 pp. ISBN 3-540-17728-0
Contents: History and Goals. - Implants and Instruments. - General Techniques for the Internal
Fixation of Small Fractures. - Preoperative, Operative, and Postoperative Guidelines. - Removal
of Implants. -Autogenous Bone Grafts. - Reconstructive Surgery. -Introduction and Overview. -
The Shoulder Girdle.- The Elbow.- The Shafts of the Radius and Ulna.- The Wrist and Carpus.-
The Hand. - The Knee. - The Tibial Shaft. - The Ankle Joint. - The Foot. - Special Indications. -
References. - Subject Index.
Springer
Preisiinderungen vorhehalten. 83.09.121

AO-ASIF - Instruments & Implants

Uploaded by

Copyright:

Available Formats

You might also like

AO-ASIF - Instruments & Implants

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

AO-ASIF - Instruments & Implants

Uploaded by

Copyright:

Available Formats

R.Texhammar C.

Contributors F. Baumgart J. Buchanan J. A. Disegi

Completely Revised and Enlarged

Springer-Verlag Berlin Heidelberg GmbH

The first edition appeared under the title:

Library of Congress Cataloging·in-Publication Data

The original AO/ASIF Instrumentation manual presented a

Berne, October 1993 Maurice E. Muller

The first edition of this book, written by Fridolin Sequin and

Stockholm Rigmor J areke Texhammar

1 Introduction: Assumption of Knowledge 1

4 Basic A 0/ASIF Technique: Aims and Principles 9

4.1 Principles and Techniques in Relation to Bone Healing 9

4.2 Aims of the AO-Technique: Stability and Biology 15

4.3 Biomechanical Aspects of the A 0/ASIF Technique 19

4.5.1 Immunology of Bone Grafting 30

5 Clinical and Special Assessment 33

5.1 Classification of Fractures 33

5.2 General Assessment in Fracture Care 35

5.3 Imaging Techniques 38

5.4 Treatment Options Closed Fractures 41

5.5 Treatment Open Fractures 43

5.6 Compartment Syndromes 45

6.1 Materials Used for AO/ASIF Instruments and

6.1.2 Materials Used for AO/ ASIF Instruments 52

6.1.3 The "Mixing" of Instruments and Implants 54

6.2 Classification of AO/ ASIF Instrumentation 59

6.3 Instruments for Fixation with Large Screws and Plates 60

6.4 A 0/ASIF Screws for Large Bone Fractures 71

6.5 Plates for Large Bone Fractures 83

6.6 The Cannulated Screw System 113

6.7 Dynamic Hip Screw and Dynamic Condylar Screw

6.8 Angled Blade Plates and Instruments 152

6.9 Small Fragment Instruments and Implants 177

6.10 Pelvic Instruments and Implants 217

6.11 Mini Fragment Instruments and Implants 227

6.12 Intramedullary Nailing Instruments and Implants 271

6.12.1 Standard Instruments for Universal Nailing 272

6.13 External Fixator Devices: Instruments and Implants 320

6.14 The Distractor 352

6.15 The Bone Forceps 358

6.16 General Instruments for Bone Surgery 360

6.17 Wiring Instruments and Implants 362

6.18 Bone Grafting Instruments . . . . . . 369

6.19 Instruments for Removal of Damaged Screws 372

6.20 Aiming Device . . . . 376

6.21 Compressed Air Machines 380

6.22 Care and Maintenance of AO/ ASIF Instrumentation 394

6.22.1 Definition . 394

7 Internal or External Fixation of Various Fractures 435

701 Fractures of the Scapula and the Shoulder Joint 435

702 Fractures of the Clavicle 440

703 Fractures of the Proximal Humerus 443

7.4 Fractures of the Humeral Shaft 447

7.5 Fractures of the Distal Humerus 451

7.6 Fractures of the Olecranon 456

7.7 Fractures of the Radial Head 460

7.8 Fractures of the Radius and the Ulna 463