Injury, Int. J.

Care Injured 45 (2014) 1011–1014

Contents lists available at ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

Technical Note

A novel technique for accurate Poller (blocking) screw placement

Andrew Hannah *, Tariq Aboelmagd, Grace Yip, Peter Hull
Department of Trauma and Orthopaedics, Cambridge University Hospitals NHS Foundation Trust, Addenbrooke’s Hospital, Hills Road,
Cambridge CB2 0QQ, United Kingdom

A R T I C L E I N F O A B S T R A C T

Article history: Achieving good results with intramedullary nailing of oblique long bone fractures at the metaphyseal–
Accepted 19 February 2014 diaphyseal junction can be difficult. There is a strong tendency for axial displacement and an association
with characteristic malalignment of the short fragment. Poller or blocking screws have been shown to be
Keywords: effective in aiding fracture reduction. While several papers describe methods for screw placement, these
Poller screw are confusing to understand, difficult to follow in clinical practice and not always applicable. Here we
Blocking screw describe a new, simple, reproducible and easy to use method for ensuring accurate Poller screw
Intramedullary nail
placement, in order to maximise the benefits of their use and achieve good overall results.
ß 2014 Elsevier Ltd. All rights reserved.

Introduction The accurate placement of Poller screws is therefore essential in

Poller (blocking) screws first described by Krettek et al. [1] are
an important adjunct for intramedullary nailing and have been
shown to be effective in aiding fracture reduction [2–5]. They help
direct the nail during insertion [5], control angular deformity [2]
and increase the stability of the bone-implant construct [1,5].
The most frequent indication for the use of Poller screws is in
oblique long bone fractures at the metaphyseal–diaphyseal
junction, where intramedullary nailing is associated with charac-
teristic malalignment of the short fragment and has a strong
tendency for axial displacement due to size discrepancies between
the diameters of the medullary canal and the intramedullary nail
[6].
By narrowing the medullary canal in the metaphyseal or flared
segment of the bone by the placement of a Poller screw, this size
discrepancy can be overcome to provide a tight mechanical fit for
the nail [1,5,6].
Accurate placement also enables 3-point fixation principles
which help to overcome the muscular and ligamentous displace-
ment forces responsible for the associated axial displacement [5,6].
The screw supplies the third point, with the other two being the
isthmus of the long bone and either the anchorage point at the tip
of the nail or the entry point [5].
* Corresponding author at: 33 Oxmeadow, Bottisham, Cambridge CB25 9FL,
United Kingdom. Tel.: +44 7773431976.
E-mail address: Andrew.hannah@doctors.org.uk (A. Hannah).
order to achieve the maximum benefit of their use, and requires
good preoperative planning. However, most articles describe
placing the screws in the concave side of the short fragment,
ensuring to avoid the convex side [2,5,6]. Others describe placing
them where ‘you don’t want the nail to go’. This can be confusing in
clinical practice and is not always applicable. In this article we
describe a new, simple, reproducible and easy to use method for
ensuring accurate Poller screw placement, in order to maximise
the benefits of their use and achieve good overall results.
Method
Using Picture Archiving and Communication Systems (PACS)
software or similar. Start by drawing a line down the long axis of
the displaced, flared segment of bone. Then draw a second line
along the plane of the fracture, ensuring to bisect the first line. Due
to nearly all metaphyseal fractures having a degree of obliquity,
this should create 4 angles; 2 acute and 2 obtuse.
For correct reduction the screws need to be placed in the acute
angles. By placing a screw in the flared or widest segment where it
will have maximal effect in overcoming any size discrepancy
between the implant and the metaphyseal diameter, it may be
possible to use just one screw and this should be the preferred site
of placement for the first screw. When the nail comes into contact
with the screw the course of the nail should then be deflected so
that the displaced segment becomes reduced in the desired
direction, due to the tight mechanical fit provided by the narrowed
metaphyseal diameter.

http://dx.doi.org/10.1016/j.injury.2014.02.029
0020–1383/ß 2014 Elsevier Ltd. All rights reserved.
1012 A. Hannah et al. / Injury, Int. J. Care Injured 45 (2014) 1011–1014

Fig. 1. This illustration of an oblique fracture of the distal femur demonstrates how
to identify the acute angles and shows the desired direction of reduction required to
overcome the displacing forces and achieve accurate reduction.

If a second screw is necessary this should be placed in the other Fig. 3. The intramedullary nail engaging the Poller screw which was placed in the
acute angle of the flared segment (distal segment in this example), accurately
acute angle which will be nearer to the isthmus and therefore have
reducing the distal femoral fracture.
less of an effect but will potentiate the effect of the first screw. It
may also be necessary to apply screws using this technique in more
than one plane in more complex fractures.

(7) If reduction could be improved further by the addition of a

Step by step
further screw, this should be placed in the acute angle nearer to
the isthmus.
(1) Draw a line down the long axis of the displaced, flared segment
of bone.
(2) Draw a second line along the plane of the fracture, ensuring to
bisect the first line.
(3) Identify your acute angles (Figs. 1 and 2).
(4) Place your screw in the acute angle of the metaphyseal or flared
segment.
(5) Insert your guide wire under fluoroscopy guidance, ensuring
the tip passes the correct side to ensure reduction.
(6) Insert your nail, which should be deflected on engaging the
screw providing reduction and compression at the fracture site
(Figs. 3 and 4).

Fig. 4. The intramedullary nail engaging the Poller screw which was placed in the
Fig. 2. An illustration of an oblique fracture of the proximal tibia, with a reverse acute angle of the flared segment (proximal segment this time), accurately reducing
obliquity to the one demonstrated in the distal femur. the proximal tibial fracture.
 A. Hannah et al. / Injury, Int. J. Care Injured 45 (2014) 1011–1014 1013

Fig. 5. Case 1: Shows the initial tibial X-ray of this 51 year old, diabetic man who fell off his push bike sustaining this closed, isolated injury. The acute angles are illustrated (a)
and the intra-operative (b) and post operative films (c) are shown.

Fig. 6. Case 2: Shows the initial femoral X-ray of this 19-year old girl who sustained multiple injuries in a RTA. The femoral fracture was a closed injury. The acute angles are
again demonstrated (a) and the intraoperative film (b) show a good reduction.
1014 A. Hannah et al. / Injury, Int. J. Care Injured 45 (2014) 1011–1014
Examples
Tibial fracture
The first screw should be placed in the acute angle of the flared
segment, as depicted by the blue circle (Fig. 5). Intra-operative
fluoroscopy shows a good reduction which has been well
maintained post-operatively.
Oblique distal third shaft femoral fracture
The obliquity of this example is opposite to the one shown
above, but again the screw should be placed in the acute angle of
the flared segment. Intra-operative fluoroscopy shows a good
reduction (Fig. 6).
Conclusion
Poller (blocking) screws are an important adjunct for intrame-
dullary nailing; aiding fracture reduction at the metaphyseal–
diaphyseal junction, and offsetting deforming forces which can
lead to malalignment. We have described a simple method in
which identifying the acute angle formed between the long axis of
the displaced fragment and the fracture line leads to accurate
reproducible placement of the blocking screw.
Conflict of interest
None of the authors had any conflicts of interest in the
production of this article.
References
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mechanical effect of blocking screws (‘‘Poller screws’’) in stabilizing tibia
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diameter intramedullary nails. J Bone Joint Surg Br 1999;81:963–8.
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third of the tibial shaft treated with intramedullary nails and blocking screws. J
Orthop Trauma 2001;15:264–70.
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