Chapter 16: Internal &

External,
Fixation
Objectives of Fixation Devices
Requirements of Implant Materials
Principles Affecting Internal Fixation
Internal Fixation Devices
AO Objectives
AO Principles
AO Technique
Jumping Screws
Other Techniques
Complications of Fixation Devices
External Fixation
Large Bone External Fixation (Ilizarov Technique)
Small Bone External Fixation of the Foot
INTERNAL & EXTERNAL FIXATION
Objectives of Fixation Devices
1. Eliminate motion at a fracture or osteotomy site.
2. Restore the normal anatomical alignment of the fractured site or the
desired position of an osteotomized segment.
3. Assist in the physiological mechanism of bone healing.
4. Permit early mobilization of the area affected by the fracture or
osteotomy.

Requirements of Implant Materials

1. Materials must be resistant to corrosive environment of the body, yet
inert to any foreign body reaction.
2. Material must have strength and durability to endure the stress loads
placed upon it during implantation, bone healing, and subsequent function
of the involved part.
3. Material must be available in various sizes and shapes and practical,
enabling fabrication into fixation devices suitable for implantation, without
the need for complicated hardware or technique.
4. Metals must be compatible with the surrounding environment, thus
reducing the pitting and crevice corrosion phenomena which would lead to
fatigue fracture of the implant device.
5. Use of similar metals within the fixation device to prevent the anode-
cathode "battery affect", or the production of hydrogen ions from saline
fluid within the body. Acidic environment leads to rapid corrosion and
fatigue fracture of implant devices.
6. Should be relatively inexpensive.

Principles Affecting Internal Fixation

1. Alignment and stability across the fracture site must be developed and
maintained during fracture healing to effect bone healing. 2. Tension
Band Principle: Load-bearing through a bone creates one convex and
concave surface subjected to compressive and tension forces.
Accordingly, implant devices are applied to the convex surface of bone
or to the side of tension, to prevent gapping from tensile forces. The
gapping forces are counteracted with proper positioning and selection of
the device. This causes counterreactive force of compression across the
fracture site, enhancing proper fracture healing.
3. Neutralization Principle: Specific anatomic sites are exposed to
multiple stresses, which include torsional and axial loads. These forces
may change with dynamics of muscle and joint activity. The various load
forces are neutralized at the fracture site with plating in combination with
bone screws to minimize movement, especially with multifragmented
fractures.

Internal Fixation Devices

1. Suture Material:
a. Absorbable and non-absorbable sutures are used to re-approximate an
osteotomy site. This is done when the osteotomy can be closed without
any tension. If a non-absorbable material is being used, this fixation
device is then considered a permanent type.
b. The only advantage of this material is that it is very easy to use.
c. The disadvantages are that is provides poor compression and low
tensile strength.

2. Stainless steel wire: 316 LVM surgical steel

a. Monofilament is better than braided to achieve compression as it is
twisted down on itself.
b. Its advantages are:
i. Its simplicity
ii. Adequate compression when used properly
iii. Minimal amount of foreign material left in the bone
iv. Acceptable in various anatomic locations independent of surface
irregularities and bone cuts.
v. Easily retrieved, if necessary, postoperatively, and visable on x-ray
c. Its disadvantages are:
i. Difficulty in achieving equal compression along the fracture/osteotomy
site
ii. Possible trauma to bone as the wire is pulled through
iii. Requires good -bone stock
iv. Becomes a permanent fixation device.
v. Fatigue fracture of wire with motion at the fracture site
d. Size used is generally 28 gauge.
e. Tension band wiring using monofilament and K-wires. This technique
provides greater stability than that provided by either component used
separately. The tension band principle applies to bones that are
eccentrically loaded. The application of a tension band device on the
tension side of a bone allows dynamic compression to be generated on
the opposite cortex.
f. MRI may be a problem if wire is present in the foot.

3. Kirschner Wire: 316 LVM surgical steel

a. Designs:
i. Come in different lengths and can also be cut to size
ii. Come as single or double ended
iii. Come as threaded or smooth
iv. Tips are either trochar (slip the least along the cortical bony surface
and have the greatest holding power), diamond, or cut tip (poorest
holding power)
b. Sizes include: .028", .035", .045", .062".

c. The advantages are:

i. Application to many sites requiring minimal dissection for fracture
immobilization
ii. Can be inserted percutaneously without the need for surgical exposure,
specifically for implantation
iii. Can be easily removed following surgery once fracture healing is
accomplished
iv. Ability to fixate multiple small fragments
v. Can prevent motion on all three body planes, including axial rotation by
using multiple pins
vi. Can immobilize joints by passing wire through a joint surface, thus
preventing undesirable motion
vii. Can be incorporated within the cast to protect fixation and maintain
position
viii. Is considered a temporary device
d. Its disadvantages are:
i. Creates a track from the external surface of the wound into the bone
ii. Can be a potential source for introducing bacteria
iii. Requires good patient compliance during the postoperative phase
iv. Threaded wires are difficult to remove
v. Threaded wires across a fracture site will maintain separation of
fracture fragments after expected necrosis occurs at fracture.
vi. Can break with the bone if exposed to excessive pressure
vii. Can migrate or slip out of the bone

4. Stelnmann Pins: 316 LVM surgical steel

a. Very similar to Kirschner wires except for their size.
b. Size ranges from 5/32 to 1 /8 inches in diameter (1.9 mm to 4.7 mm).
c. Their rigidity is proportional to the fourth power of their diameter (as
with K-wires).
d. Advantages are the same as with K-wires.
e. Disadvantages are the same as with K-wires.
f. The primary stabilization of subtalar arthrodesis has frequently been
performed using these pins.
g. Are well suited to providing provisional fixation of subtalar and ankle
arthrodesis as well as calcaneal fractures.

5. Absorbable Pins (Polydioxanone/Polyglycolide): At the present

time there are two types of pins available. They were originally designed
for fixation of osteochondral fragments, which were previously treated via
excision and abrasion or fixation with K-wires, screws, or adhesives, which
would leave extensive osteochondral defects.
a. Orthosorb (polydioxanone) (Johnson & Johnson):
i. This pin is available in only one length (1.3 mm x 40 mm long) and is
very flexible.
ii. A tapered variety allows for better compression of osteotomies as they
are inserted into the pilot hole
iii. Has been used with success in digital fusions because of its flexibility
iv. Can be cut with a bone cutting forceps
v. Lose their strength in 4-8 weeks and are totally absorbed in 9-12
months
b. Biofix (self reinforced polyglycolide)(Acuflex):
i. Various diameters from 1.5 mm to 4.5 mm
ii. Various lengths from 10 mm to 70 mm and is very rigid
iii. Lose their strength in 4-8 weeks and are totally absorbed in 6
months
iv. Must be cut with a bone saw or it will shred

6. Staples: Various 2 prong and 4 prong staples are available and are
supplied with templates to assure proper implantation. Available in
surgical
steel and titanium.
a. Their application is limited and are best suited for bones with high
cancellous/cortical ratios.
b. When used primarily in diaphyseal bone there is a propensity for the
cortical bone around the staple legs to become communited as the staple
is inserted, resulting in compromised fixation.
c. Advantages are:
i. Easily removable
ii. Can be a permanent implant
iii. Provides fixation on one plane developing static compression across
the fracture fragment site.
d. Disadvantages are:
i. Should not be used in incomplete fractures independently, unless
secondary devices or complete non-weight bearing are utilized.
ii. Staples can dislodge
iii. Staples can fatigue fracture
e. Have been used for calcaneal osteotomies, triple arthrodesis, tib-fib
syndesmosis diathesis, medial and lateral malleolar fractures (with
malleolar
screw), and epiphyseal plate injuries.

7. Osteoclasps: 3/16 LVM stainless steel

a. Available in five sizes, 8 mm, 10 mm, 12 mm, 14 mm, 16 mm.
b. The device requires secondary instrumentation for template positioning
of drill holes, and additionally, a tension stat to implant the osteoclasp
under proper tension.
c. Advantages:
i. Can be used in various anatomic locations without the need for
additional surgical exposure
ii. Completely internal and can be considered a permanent implant
iii. Creates fixation with dynamic compression across the fracture site
d. Disadvantages:
i. Limited to incomplete osteotomy where cortical hinge is intact on the
opposite side of placement of the osteoclasp device
ii. Technical difficulty with implantation
iii. Implant may have to be remodeled which weakens its compression
force and may result in spontaneous loosening

8. Bone Screws: Are used to reappose fracture fragments, their primary

advantage over any other type of fixation device is that they can provide
compression and thus more rigid fixation. Cortical bone screws require
pretapping of drill holes and the thread is finer, whereas cancellous bone
screws can be used for self-tapping locations to create a lag effect across a
fracture site. Cancellous screw threads are much larger and grasp greater
surface area of bone to achieve fixation.
a. Four basic structural dimensions are employed to precisely characterize
screws:
i. Root or Core diameter is the minimal diameter of the screw not including
the threads (Fig. 2).

NOTE* The tensile strength of screws is proportional to the square of the

root/core diameter, and the shear strength of screws is proportional to
the cube of the root/core diameter.
ii. Thread diameter is the maximal diameter including the screw threads
(Fig. 1).
iii. Screw pitch is the distance between two successive threads (fig. 3).
iv. The lead is the distance a screw advances when turned one complete
revolution.
b. Other screw parts are:
i. Screw head: either cruciform or hexagon
ii. Screw land: the undersurface of the screw head
iii. Screw tip: either round, pointed, or fluted
Al 4.0 mm Partially threaded cancellous screw 1.75 mm pitch

B2 4.0 mm Fully threaded cancellous screw 1.75 mm pitch (Formally 3.5 mm

cortical screw

C3 3.5 mm Fully threaded cortical screw 1.25 mm pitch

D4 3.5 mm Fully threaded cancellous screw 1.75 mm pitch

Reprinted from Ruch JA, Vito GR Corey SV (eds); Podiatry Institute Internal Fixation Workbook. 8th ed.,
Podiatry Institute Publishing, Tucker, Georgia, 1992, with permission
iv. Screw shank: the distance between the land and the start of the screw
runout (Fig. 4)
v. Screw runnout: the distance from the end of the shank to the first thread
( Fig. 5).
vi. Screw thread: either assymmetric (buttress) or symmetric (Fig. 6)

NOTE* Bone possesses a significantly lower modulus of elasticity than metal

alloys. The buttress AO thread is designed to maximize the volume of bone
between threads and increase the holding potential of the screw in the
weaker bone matrix.

c. Cortical Screws: (see figure 7)

i. Function as either a positional screw (provide plate fixation) or a lag screw
(exerts compression)
ii. Compression is only achieved when the threads of the screw do not
engage the cortex of the near osteotomy or fracture fragment, accomplished
by overdrilling.
iii. Cortical screws measuring 3.5 mm in diameter are used in lag fashion to
provide interfragmentary compression in the distal fibula, rearfoot, and
occasionally the metatarsals.
iv. Screws measuring 2.7 mm, 2.0 mm, and 1.5 mm are also employed to
stabilize metatarsal fractures or osteotomies. Screws measuring 1.5 mm are
used in the proximal phalanx of the hallux for fracture fixation.
v. When screws are used alone for fragment fixation, two smaller screws
provide increased resistance to shear and torsional stresses.
vi. When screws are used for interfragmentary compression, they should be
inserted so that their direction bisects the perpendiculars to the fracture line
and the long axis of the bone involved.

Note* If one screw is used for a base wedge osteotomy with an intact cortical
hinge, the angle of insertion of the screw should bisect the perpendiculars of
the long axis of the osteotomy and the long axis of the bone. If the screw is
placed at an angle greater than this, the cortical hinge will disrupt.

vii. Sufficient screw fixation can usually be obtained with oblique and spiral
fracture patterns only when the fracture line is at least twice as long as the
bone's diameter.
viii. Short oblique or transverse fractures, therefore need an interfragmentary
lag screw and neutralization plate.
d. Cancellous Screws: (see figure 7)
i. Come either fully or partially threaded
ii. Cancellous screw thread height is greater than that of cortical. This allows
for greater purchase in the softer metaphyseal and epiphyseal bone for which
they were designed.
iii. Screw head fixation can be augmented in osteoporotic bone with a
washer.
iv. If the threads of a cancellous screw are left in a position crossing the
interface between two fragments, no compression will be achieved, as the
lag affect that is desired from this screw will be negated. It then acts as a
cortical screw.
v. Cancellous screws 6.5 mm in diameter are used in ankle and subtalar
arthrodeses.
vi. Lisfranc's injuries are amenable to 4.0 mm cancellous screws.
vii. Fractures of the talus and calcaneus are frequently stabilized with
cancellous screws (in these locations are generally augmented with washers
or small plates).
e. Washers:
i. Generally used in osteoporotic bone.
ii. Used with cancellous screw for increasing the purchase power on the near
fracture cortex.
iii. Can be used with screws to provide increased surface area as well as
barbs for the reattachment of ligaments or transferred tendon insertions.
f. Malleolar Screws:
i. Are self-tapping and possess a sharp pointed tip that was designed to allow
insertion without predrilling.
ii. Due to their large size, 4.0 cancellous screws have replaced them.
g. Cannulated screws: The complications involving placement of screws in
complicated fractures can be greatly minimized with this type of screw.
i. This type of screw can be inserted over a guidewire through its entire
length, after the guidewire is properly placed in the bone. This minimizes
bony trauma.
ii. When a cannulated screw is to be used, the K -wire (guidewire) serves a
dual purpose of maintaining reduction and providing a guide for screw
placement.
h. Herbert Screw:
i. Originally designed for osteochondral fractures (also used for scaphoid
fractures of the hand), due to the absence of a screw head.
ii. Characterized by the presence of threads with different pitches and leads
on both its proximal and distal ends. The distal threads feature a tighter pitch
and smaller lead and are separated from the proximal ones by an intervening
smooth shank. This allows for interfragmentary compression.
i. Reese Arthrodesis Screw: Right/lefthanded threaded screws which are
used for digital fusions.

Note* A screw can be used alone for internal fixation whenever the fracture
or osteotomy is at least twice as long as the diameter of the bone at the
level of the fracture or osteotomy.
A screw inserted at right angles to the fracture or osteotomy plane gives the
best interfragmental compression, but provides no stability under axial
loading. A screw inserted at right angles to the long axis of the bone gives
the best resistance to axial loading, but decreases the interfragmental
compression. Based on the previous 3 principles, a cortical lag screw is
inserted so that it bisects the angle formed by the perpendicular to the
fracture plane and the perpendicular to the long axis of the bone

9. Intermedullary Fixation (Nails): These are long pieces of metal of

various available diameters which are placed in the medullary canal of a
fractured/osteotomized long bone to stabilize the site.
a. They are:
i. Rush pins
ii. K-wires
ii. Inyo nails (tapered V-shaped stainless device used for fractures of the
distal fibula)
b. Are wedged into the medullary canal after the canal is reamed to a
diameter slightly smaller than the nail to be used, and then removed after
healing is completed.
c. Of all the internal fixation devices used, this one delays bone healing the
most by damaging the medullary blood vessels when it is inserted.
d. The other major drawback it is limited control of the rotational forces of the
fracture fragment.

10. Plate Fixation: Are temporary fixation devices which serve a particular
function and then are removed. Plates can function in several fashions,
depending upon how they are applied and the resulting bone-plate construct
geometry. These functions include rigid fixation through interfragmentary
compression, buttressing, and neutralization.
Depending upon the mechanical circumstances, a plate may provide more
than one of these functions.
a. The following plates are utilized:
i. Static Compression Plates: Tension is applied to the implant and
compression is achieved at the fracture interface.
ii. Dynamic Compression Plates: Beyond the compression of the
fracture achieved through static compression, the implant is subjected to
a physiologic load which generates additional compression at the fracture
plane
iii. Neutralization Plates: Initially a shaft fracture may be fixated by
interfragmental compression with a lag screw. A plate is then applied to
neutralize or absorb-any disruptive forces; torsional, shear, or bending to
which the bone and osteosynthesis may be subjected
iv. Anti-Glide Plates: Are used as neutralization plates but placed on the
posterior aspect of the fibula.
v. Buttress Plates: Are used to maintain separation of bone during bone
grafting procedures to gain or maintain length. Are generally used to
resist the tendency of metaphyseal fracture fragments to displace when
subjected to compressive forces. Specifically designed plates by the AO
group are spoon and cloverleaf plates for the distal tibia, and the
malleable H or double-H plates for the calcaneus.
b. Pre-stressing the plate results in static interfragmentary compression,
and is performed by contouring the plate so that its center sits away from
the bone to which it is applied. The screws securing the plate ends are
inserted and tightened first (pre-stressing the plate in tension) so that as
sequential screws are applied (progressively closer to the center) axial
compression is developed along the underlying bone. In addition,
eccentrically plated screws may be inserted (as a compression device) for
interfragmentary compression.
c. Plates also function to protect lag screw fixation. Oblique or spiral
fracture of the metatarsals or the distal fibula can be stabilized with
interfragmentary lag screws. The addition of a plate then serves to
neutralize the bending, torsional, and shear forces that would otherwise
jeopardize the fixation obtained by lag screws alone.
d. The AO group has developed 1 /3 and 1 /4 tubular plates which are
easily contoured.
e. The advantages of plates are:
i. Allows for complete reduction of fracture fragments and proper
anatomical alignment.
ii. Can be implanted permanently or removed at a later date.
iii. Creates rigid fixation with stabilization and/or dynamic compression
across the fracture site.
f. The disadvantages are:
i. Significant amount of surgical dissection for implantation of plate and
screws.
ii. High degree of difficulty with irregular or multifragmented bone
fractures.
iii. Technical difficulty for implantation, potential fatigue fracture of bone
plate with motion.
iv. Should be applied to the tension side of the fracture to avoid
breaking the bone plate.
iv. Results in a degree of bone necrosis beneath the plate.

11. External Fixator Devices: These devices are available in a variety of

sizes depending upon the location to be used. Their prime indication is
severe trauma, especially associated with open fractures. Also can be
used in the treatment of infected fractures, non-unions involving the
ankle, arthrodesis of the subtalar joint or ankle joint, acute and chronic
OM, and chronic septic arthritis.

NOTE* Specific guidelines for their use have been outlined by Kenzora and
Edwards and associates in The Foot and Ankle. They recommended the
use of various configurations of Hoffman's external fixators in order to:
a. Stabilize open fracture-dislocations
b. Maintain length where bone is lost or extensively comminuted
c. Prevent soft tissue contractures
d. Control joint position for delayed ankle arthrodesis
e. Provide easy access for bone and soft tissue reconstruction

a. Charnley compression clamp: Has been utilized in combination with

Steinmann pin fixation. It is applied on each side of the extremity and
attached to an exiting pin. Turn-buckle style adjustments are made on
each side of the extremity forcing compression across the fracture site.
b. Hoffman fixator devices: Were designed for the small bones of the
hands and feet, and have greatly enhanced the use of external fixator
techniques in fracture repair and bone grafting techniques.
c. Advantages:
i. Ability to be adjusted during the healing phase
ii. It is only a temporary device
iii. Its ability to provide rigid fixation while allowing ready access to
surrounding soft tissues for debridements and dressing changes as necessary
iv. Neighboring joint motion can be preserved
d. Disadvantages:
i. Difficult to use and requires special instrumentation
ii. Pin-tract loosening and infection
iii. Requires good patient compliance
iv. Creates a bulky external apparatus which will hinder the activity of the
patient

AO Objectives
1. Atraumatic operative technique
2. Accurate anatomical reduction
3. Rigid internal compression fixation 4. Avoidance of soft tissue damage
5. The AO tenet: "Life is movement, movement is life".

AO Principles
1. Intrinsic Factors Affecting Stable Fracture Reduction:
a. Stable fractures:
i. Are transverse fractures
b. Unstable fractures:
i. Long oblique fractures
ii. Comminuted fractures
iii. Spiral fractures
c. Potentially stable fractures:
i. Short oblique

2. Extrinsic Factors Affecting Stable Fracture Reduction:

a. The disruptive mechanical forces are bending, shear, and torsion.

3. Mechanical Basis for Stable Fixation:

a. Types of interfragmental compression
i. Static compression: a constant and uniform force across a
fracture/osteotomy site, accomplished by lag screw technique, a preloaded
plate, or external fixator.
ii. Dynamic compression: is the combination of a statically loaded fixation
device to a functionally loaded fracture configuration (the tension band
concept).
b. Splintage: A technique applied when interfragmental compression is not
possible and is used in combination with interfragmental compression when it
alone is not adaquate to provide stable fixation. c. Combinations:
combination of techniques of interfragmental compression and splintage (i.e.
a single lag screw plus reinforced by a plate).

4. Techniques of Stable Fixation:

a. Single lag screw: A cortical screw with a glide hole or a cancellous screw
with all the threads on the distal side of the fracture fragment. A single lag
screw can provide adequate interfragmentary compression, however, is not
able to withstand shearing and bending loads, so the fracture/osteotomy
must be protected.
i. Angle of screw insertion: Should be placed so that the angle of the screw
bisects the perpendicular of the fracture/osteotomy and the perpendicular of
the longitudinal axis of the bone. If the angle of the screw deviates from the
plane of the fracture, there is a shift of the near fragment in the direction of
the course of the screw as the screw is tightened and compression is
created.
b. Multiple lag screws (two or more): Are used in a long/oblique or spiral
fracture, where the length of the fracture is at least twice the diameter of
the diaphyseal bone involved.
i. Angle of screw insertion: when fixating a fracture/osteotomy with
several screws, the first screw should be perpendicular to both cortices
and be centrally placed. The second and third screws (placed on either
side of the first screw) are placed perpendicular to the plane of the
fracture. This prevents a frontal plane shift, called the shear effect, of the
longitudinal relationship of the fracture fragments. These secondary
screws can also be placed so that they bisect the angle between the
perpendicular of the fracture and the perpendicular of the cortical surface.
This reinforces interfragmentary compression.

AO Technique
1. Instrumentation:
i. Thread hole drill bit: (1.1, 1.5, 2.0, 2.5, 3.2 mm)
ii. Glide hole drill bit: (1.5, 2.0, 2.5, 2.7, 3.5, 4.5 mm)
iii. Countersink: (Mini Fragment Set 1.1 and 2.0 mm tip) (Small Fragment
Set 2.0 mm tip) (Large Fragment Set 3.2 and 4.5 mm tip)
iv. Depth gauge: (Mini/Small/Large)
v. Tap: (1.5, 2.0, 2.7, 3.5 mm @ 1.25 pitch) (3.5 mm @ 1.75 pitch) (4.5
and 6.5 mm)
vi. Screw Driver: (Cruciform/Hexagon head)
v. Drill and Tap Sleeve: (protection for the soft tissue/ reduces the need
for excessive retraction when the drill bit Is aimed obliquely at the
bone/the serrated end anchors well to cortical bone and prevents slippage
of the drill bit)
2. Sequence For Screw Insertion:
a. 1.5 mm Cortical Screw
i. Pre-drill (0.035 K-wire= 0.9 mm)
ii. Thread Hole (1.1 mm)
iii. Countersink (Mini)
iv. Overdrill near cortex (1.5 mm)
v. Depth gauge (Mini)
vi. Tap (1.5 mm)
vii. Screw Placement
b. 2.0 Cortical Screw
i. Pre-drill (0.045 K-wire= 1.1 mm)
ii. Thread Hole (1.5 mm)
iii. Countersink (Mini)
iv. Overdrill near cortex (2.0 mm)
v. Depth gauge (Mini)
vi. Tap (2.0 mm)
vii. Screw Placement
c. 2.7 Cortical Screw
i. Pre-drill (0.062 K-wire= 1.6 mm)
ii. Thread Hole (2.0 mm)
iii. Countersink (Small)
iv. Overdrill (2.7 mm)
v. Depth Gauge (Small)
vi. Tap (2.7 mm)
vii. Screw Placement
d. 3.5 Cortical Screw
i. Pre-drill (0.062 K-wire= 1.6 mm)
ii. Thread Hole (2.5 mm)
iii. Countersink (Small)
iv. Overdrill (3.5 mm)
v. Depth Gauge (Small)
vi. Tap (3.5 mm)
vii. Screw Placement
e. 3.5 mm Cancellous Screw
i. As with 3.5 Cortical Screw but eliminate the 2.5 mm Thread Hole
f. 4.0 Cancellous (partially threaded)
i. Pre-drill (0.062 K-wire= 1.6 mm)
ii. Thread Hole (2.0 mm)
iii. Countersink (Small)
iv. Overdrill (3.5 mm)
v. Depth Gauge
vi. Tap (3.5 mm)
vii. Screw Placement
g. 4.0 Fully Threaded Cancellous Screw
i. Pre-drill (0.062 K-wire= 1.6 mm)
ii. Thread Hole (2.0)
iii. Countersink (Small)
iv. Depth Gauge
v. Tap (3.5 mm)
vi. Screw Placement
h. 4.5 Cortical Screw
i. Pre-drill (0.63 K-wire= 1.6 mm)
ii. Thread Hole (3.2 mm)
iii. Countersink (Large)
iv. Overdrill (4.5 mm)
v. Depth Gauge
vi. Tap (4.5 mm)
vii. Screw Placement
i. 6.5 mm Cancellous Screw (partially threaded)
i. Pre-drill (5/64 K-wire)
ii. Thread Hole (3.2 mm)
iii. Countersink (Large)
iv. Depth Gauge
v. Tap (6.5)
vi. Screw Placement
j. 3.5 mm Cortical Screw (using a T-Sleeve)
i. 3.5 mm drill (proximal cortex only)
ii. 3.5 mm x 2.0 mm drill sleeve
iii. 2.0 mm thread hole of the far cortex
iv. Countersink
v. Depth Gauge
vi. Tap (3.5 mm)
vii. Screw Placement
k. Exercise: Modified Austin With 2 x 2.7 mm Cortical Screw Placement
i. Osteotomy performed with lateral shift of the capitol fragment
ii. Temporary fixation (0.045 K-wire)
iii. Temporary fixation: pilot hole for the proximal screw (0.062 K-wire)
iv. Pilot hole for the distal screw (0.062 K-wire)
v. 2.0 mm thread hole (distal screw)
vi. Countersink (distal screw)
vii. 2.7 mm over drill (distal screw)
viii. Depth gauge (distal screw)
ix. 2.7 mm tap (distal screw)
x. Insert 2.7 mm distal screw
xi. Remove proximal temporary fixation
xii. Proximal screw insertion (as just described)
xiii. Remove distal temporary fixation
xiv. Tighten screws

3. Plating Procedures:
a. Prestressed Plate: Because of the linear design of these plates, this
technique is best used in long bone fractures. The axial load created by a
prestressed plate is a form of static compression, and can be
accomplished three ways:
1. Load Screw Technique:
 The most common plate technique in the foot and ankle.
 These plates are thin and are semi 1 /3 and 1 /4 round.
 They are to be used for tension only and do not provide
rigidity against bending (provided by the thicker Dynamic
Compression plate).
 Performed by using eccentrically drilled holes, (for the
initial two holes) one just proximal and one distal to the
fracture/osteotomy site. As the screws are tightened down
they move the fracture fragments together. This can be done
as a result of the ovoid design of the screw holes in the plate.
These are the load screws. The other screws must be centrally
placed or they will dislodge these load screws.
 To prevent the fracture surface from gapping on the opposite side of
the tension surface, the plate can (and should) be prebent at its center.
It now acts as a leaf spring and resists gapping of the opposite cortex.
 The use of this concept is limited to transverse
metatarsal fractures and arthrodesis of first metatarsal-
cuneiform arthrodesis.

ii. Dynamic Compression Plate: This incorporates the load screw

technique with the added effect of geometrically designed slots within a
plate.
 These plates are thicker and stiffer than tension plates.
 These geometrically designed slots have two features: they are oblong
 and longitudinally placed, and they have two different slopes (the first
acute slope is the compression slope/the second slope is the gliding
slope). Both of these features allow for linear motion.

 All the screws can be used as load screws (because there is space for the
first two screws to glide after the other screws are tightened down).
 There are individual plates corresponding to the 2.7 mm/3.5 mm/4.5 mm
cortical screws.
iii. Tension Device: This can be done only with large bones. It is done by
anchoring a tension device to one of the fragments and to a free end of a
plate, then anchoring the plate to the other side of the fragment and then
tightening the tension device. This causes interfragmental compression.
Jumping Screws
In case of screw failure you must have a backup or alternative. This explains
how to change screws properly
1. To go from a 1.5 to a 2.0 mm screw: Use a 1.5 mm thread hole,
followed by a 2.0 overdrill

2. To go from a 2.0 to a 2.7 mm screw: Use a 2.0 thread hole followed by

a 2.7 overdrill (may need to re-countersink)

3. To go from a 2.7 to a 3.5 mm cancellous screw: Use a 3.5 overdrill

4. To go from a 2.7 to a 3.5 mm cortical screw: Use a 2.5 thread hole

followed by a 3.5 overdrill

5. To go from a 2.7 to a 4.0 mm cancellous screw (may be the best

choice): Needs no instrumentation

6. To go from a 3.5 cancellous to a 3.5 mm cortical screw.: Use a 2.5

mm thread hole

7. To go from a 3.5 cortical to a 3.5 mm cancellous: Needs no

instrumentation

8. To go from a 4.0 cancellous to a 3.5 mm cortical screw: Use a 2.5

thread hole followed by a 3.5 overdrill

NOTE* Never retap after the first screw fails

Other Techniques
1. Splintage: A technique used to splint or protect a reduced fracture. The
primary uses of splintage are: when interfragmental compression cannot be
used, epiphyseal fractures, and to protect a tenuous interfragmental
compression.

2. Circlage Wiring: The classic application in podiatry is the dorsal loop

technique for an abductory closing wedge osteotomy, even though is has
proven to be the weakest form of internal fixation. It does provide apposition
of the osteotomy surfaces, but provides little stability. The most secure
fixation is two loops in a 90 degree orientation to each other

3. K-wires: A single K-wire rarely provides any rigidity, however, crossed K-

wires are best. This is not without its shortcomings as distraction of fracture
fragments can occur. K-wire fixation alone does not afford interfragmental
compression. K-wires do offer stability when used in combination with
intraosseous loop techniques. Threaded K-wires are rarely used as they are
mechanically unsound.

4. Tension Banding: Monofilament wire threaded in a figure 8 fashion, used

in combination with two K-wires to give interfragmental compression (Figure
11). Good with Jones fracture, and some ankle fractures. The plane of
insertion of the 2 K-wires must be parallel to the plane of the drill hole for
passage of the monofilament wire
 Figure 11: Tension Band Wiring Techniques
Reprinted from Ruch JA, Vito GR, corey SV (eds); Podiatry Institute Internal Fixation Workbook. 8th ed.,
Podiatry Institute Publishing, Tucker, Georgia, 1992, with permission
 Note* The tension band principle is applied when an eccentric load is placed
on a bone, and reduction is attempted. The eccentric load creates a
concavity on one side (which is under tension), and a convexity on the
other side which is under compression. The tension band absorbs the
tensile force, and the bone (load beam) absorbs the compressive forces.
The 2 areas that are easily accessible to this principle in podiatry are the
5th metatarsal and the two malleoli Principles:
a. Neutralize the distracting force and convert to a compressive force
b. Apply the tension band to the tension side only (convex side)
c. K-wires eliminate the rotational instability

Complications of Fixation Devices

1. Infection: Despite long-standing efforts directed at eliminating this
complication, there appears to be an irreducible minimal infection rate
destined to plague both patient and physician. The potential exists for the
growth of resistant bacterial strains or superinfections as a result of
increased use of antibiotics. Studies involving the use of prophylactic
antibiotics have shown a decrease in the incidence of postoperative
infections when fixation devices are used (first-generation cephalosporins
given preoperatively provide good coverage against Staph aureus and many
gram(-) rods, and are most widely used). Implants frequently need to be
removed in the presence of a deep infection, however, should be left in place
in the absence of bony union even with the presence of an infection
(infections are difficult to manage without stability, and so do better with
stabilization).

2. Slippage of the Fixation Device: Screws, K-wires, as well as the rest of

the fixators can lose purchase and slip out of place. When this happens, the
device must be removed and replaced with an alternate.

3. Mechanical Failure: Has not been a frequent problem.

4. Inappropriate Use of Fixation Devices: This is a significant problem.

Next to infection this is the most common cause of implant failure.

5. Stripping of a Screw Head/ Breakage of a Screw: When stripping

occurs a vise grip is used. When a cancellous screw is removed after many
months it can break. A cancellous screw is unable to cut bone when it is
backed out, and if excessive torque is applied when bone has grown in
around the smooth shank, the screw can break.

External Fixation
An external fixator can be used in many different ways in the fixation of the
osseous skeleton. However, the use of an external fixator is presently limited
in foot an ankle surgery. With the understanding of the techniques and
training now available, should become a more popular method in the
surgeon's armamentarium. The techniques discussed will be divided into
large bone and small bone fixation

Large Bone Fixation

1. Ilizarov technique: This method of external fixation was developed in
Kurgon, Russia and has been used successfully to treat surgical and
traumatic fractures, osteomyelitis (without sequestrectomy or even
antibiotics), non-unions, osteotomies, fusions, pseudoarthrosis, angular
deformities, limb shortenings, and joint contractures using a surgical
technique that respects osteogenic tissues and their vascular supply while
preserving the weightbearing function of the limb. This is all due to the
massive neovascularization coupled with mechanical control of the limb
permitting not only histogenesis of bone, muscles, nerves, and skin, but
also transformation of pathological states such as osteomyelitis, fibrous
dysplasia and pseudoarthrosis into normal bone. This technique requires
strict adherence to certain surgical, anatomic, and mechanical principles.
Surgically, it is necessary to maintain the periosteum, endosteum, and
bone marrow with its blood supply, via transection of only the bony
cortices.
It is important to understand that this technique is very difficult to master,
has a long learning curve, and is technically demanding. Because of the
complexity of the different methods of assembly, no surgical technique
brochure could possibly explain all of the variations of usage.
a. Components: The Ilizarov external fixator is a modular apparatus
consisting of parts that can be assembled in an unlimited number of
configurations. With one or more rings affixed to each bone fragment, the
frame can be used to compress, distract, angulate, or rotate bone segments
with respect to each other. In this manner, deformities can be overcome
while at the same time the limb is made stable enough to permit weight-
bearing and functional use.
i. Transfixation wires: The mainstay of the Ilizarov system, consisting of 1.5
and 1.8mm the latter utilized for lower extremity adult pathology/deformity.

NOTE* After a transfixation wire is inserted, one end of the wire is secured to
the frame, the other end of the wire is tensioned before final fixation

ii. Olive wires: A Kirschner wire with a small bead on it used to abut
against cortical bone to stabilize or pull bone segments. Can serve several
functions: can act as a stabilizing element, can act as a fulcrum or rotation
point around which a deformity correction occurs, or can act as a traction
element to pull bone in a desired direction
iii. Rings: Can be either half-rings, full rings, 5/8 circle rings and Omega rings
(for the shoulder). The half-rings can be bolted together (sizes from 80-240
mm in diameter) and then the wires are secured to them. One ring can be
bolted to another ring via threaded rods tightened by a nut on the end.
iv. Arches: Arches are large, heavy, curved plates used most commonly for
fixation of the upper femur, and come is three diameters, 90, 110, and
140mm
v. Nuts and bolts: Among other things, these secure the half-rings together.
The bolts come in 10, 16, and 30mm lengths and the head of the bolt fits a
10mm metric wrench
vi. Fixation bolts: Are used to secure wires to the rings and are either
cannulated, grooved, or cannulated with a tapped head. A cannulated bolt is
used when a wire passes across the center if a hole at the point of fixation, a
grooved bolt is used whenever a wire is tangential to a fixation hole, and a
cannulated bolt with a tapped head is used when wire fixation is needed in a
crowded situation where a connecting rod, socket, plate, or other hardware
must be attached to the same ring position as a wire.
vii. Washers: There are plain washers, grooved washers, and paired spheric
washers. A grooved washer can serve for wire fixation anywhere, and if a
wire is far off a ring's plane for fixation, enough washers can be stacked on a
long bolt to secure the wire. A pair of grooved washers surrounded by a pair
of nuts on a threaded rod can also secure a wire. A pair of spheric washers
are useful in compensating for angulation between a ring and a threaded rod
and allow about 7.5° of anglation in a hole
viii. Threaded rods: Are the basic connectors between the support rings and
come in lengths from 30 to 400 mm
ix. Telescopic Tubes: Are used to prevent frame deformity when there is a
long distance between the support rings
x. Ratchet telescopic rods: Incorporates a ratchet mechanism to simplify
distraction, which the patient can rotate to extend the rod 0.25 mm, and is
calibrated so that the surgeon can assess the elongation or shortening
xi. Posts: Come with one, two, three, or four holes, can have many functions.
Two being to act as a fixation point for wires off the plane of a ring, to act as
a swivel for ring rotation as well as points for pushing or pulling a ring
xii. Buckles: Were Ilizarov's original fixation device
xiii. Plates: Can function as wire attachment points, as a stable supporting
element in push configurations designed simultaneously to angulate and to
translate ring clusters with respect to each other, or to simply enlarge the
diameter of, a small ring
 Straight plates
 Paddles
 Twisted Plates
xiv. Sockets: They function not only as interconnectors between threaded
rods, but also as spacers to raise a point of attachment off the plane of a ring
or plate
xv. Bushings: Due to its configuration, will slide along any rod in a fixation
frame. The free movement of such an assembly is used to build a
mechanism for counterrottation of rings or traction on threaded rods or as a
slide assembly to move componants along threaded rods
xvi. Wire tensioners: Are either spring-loaded or threaded. Are used to, apply
tension to the transfixation wires

b. Ring selection: Allow 2-3 cm of clearance between the inner edges of rings
and the “skin”
c. Wire and pin placement: The pins and wires must be placed in certain
locations at specific anatomical levels. The following diagrams show proper
pin placement at different levels
d. Wire tensioning: To achieve enough stiffness in the wires to maintain
stability and overcome intrinsic tissue resistance, the wires must be
stretched like a tightrope. The multiplanar fixation with tensioned wires
provides an optimal environment for bone formation. The fixation resists
bending and torsion, thus minimizing shear forces at the bone-healing
interface. The use of a Richards dynamometric wire tensioner is preferred to
accurately tension each wire. A calibration scale is noted on this instrument
from 50 to 130 kg of force. A tension of 70-110 kg is utilized with a 1.5 mm
diameter wire and 70-130 for a 1.8 mm wire
e. Hinge placement: Complex deformities consist of more than one of the
following deformities: length, rotation, angulation, and translation. The actual
sequence of correction of complex deformities can vary, however, in general,
length must be achieved prior to offset and translation, and rotation should
be accomplished last. Once the plane of deformity and the maximum
angulation and translation have been determined, determination of hinge
placement is necessary. This is worked out by geometry (see Figs 1-5)
f. Ilizarov corticotomy: The method of limb lengthening or bone
lengthening consists of external distraction of a surgically created
osteotomy or corticotomy via a percutaneous, subperiosteal
incision, perserving periosteum and endosteum. After a latency
period after a corticotomy anywhere from 7-14 days, distraction of
the bone can begin, anywhere from .5 to 1.0 mm per day. This is
called distraction osteogenesis
g. Techniques in fracture reduction: Several factors are taken into
consideration when a frame is constructed: size and number of
fracture fragments, plane of the fracture lines, condition of the soft
tissues, and proximity of the fracture fragment of the joint and
intra-articular involvement. As a general rule one should achieve 2
levels of fixation in each major fracture fragment (2 rings applied to
any bone segment). The diatance from a fracture line to a ring is
usually 3-4 cm, giving enough room for compression or distraction,
or angulation and translation. The angle formed by 2 wires crossing
a fracture fragment should approach 900 for maximum stability.
Intra-articular fractures should be reduced prior to diaphyseal
fractures
h. Illustration of techniques for the foot and ankle:
 Malleolar fractures

Standard assembly for a transsyndesmotic fibular fracture of the

posterolateral rim with medial lesion or in presence of Volkmann fragment:
a) Ilizarov technique (Malzev-Kirienko);
b) Hybrid Advanced technique with internal osteosynthesis (1 = open
reduction, 2 = centralization, 3 = fixation) (Catagni).

Catagni, M.A., Malzev, V., Kirienko, A., Advances In Ilizarov Apparatus Assembly, A. Bianchi Maiocchi (ED),
Medicalplastic srl, Milan, 1994
The universal joint allows movement of the ankle during the postoperative
period.

Standard assembly for a malleolar fracture (Malzev-Kirienko).

Lateral view of the assembly for reduction and compression of the medial
malleolus.

Catagni, M.A., Malzev, V., Kirienko, A., Advances In IlIzarov Apparatus Assembly, A. Bianchi MaIocchi
(ED), Medicalplastic srl, Milan, 1994
 Distal articular (tibial plafond fractures)

Standard configuration for a typical comminuted fracture of the tibial plafond

(Malzev-Kirienko).

Catagni, M.A., Malzev, V., Kirlenko, A., Advances In IlIzarov Apparatus Assembly, A. Bianchi MaIocchi
(ED), Medicalplastic srl, Milan, 1994
CatagnI, M.A., Malzev, V., Kirlenko, A., Advances in Ilizarov Apparatus Assembly, A. Bianchi Maiocchi
(ED), Medicalplastic srl, Milan, 1994
 Equinus foot

Apparatus assembly after correction of the equinus foot;

a) Standard apparatus assembly for correction of an equinus foot deformity.

b) Diagram of wire insertion at trascalcaneal and transmetatarsal sites. A
fourth wire in the tarsus may be placed according to severity of the case
(Malzev-Kirienko).

Catagni, M.A., Malzev, V., KIrienko, A., Advances In IlIzarov Apparatus Assembly, A. Bianchi Maiocchi
(ED), Medicalplastic srl, Milan, 1994
Small Bone External Fixation of the Foot
1. Orthofix modulsystem (Pennig minifixator): Allows for secure
fragment fixation, with minimum of invasive surgery
a. Can be applied under fluorscopy, using minimally invasive threaded rods
b. Allows for 2 pairs of wires to be placed as little as 6 mm apart
c. Fracture reduction is possible on all planes
d. Allows for lengthening, treatment of non-unions, soft tissue correction, and
any technique for compression or distraction

Indications for use:

 Fractures
 Aseptic and infected non-unions
 Corrective osteotomies
 Lengthening
 Replantation

PROXIMAL FRACTURES OF THE FIRST METACARPAL

ASEPTIC AND INFECTED NON-UNIONS
CORRECTIVE OSTEOTOMIES
LENGTHENING