PGY-1 CURRICULUMBasic Orthopaedic Skills

Indiana University School Medicine

Department of Orthopaedic Surgery

July, 2013

GOALS

1. Understand the indications for percutaneous pinning (PP) of fractures (fx)

2. Understand the indications for damage control orthopaedics and stabilization with external fixation (EF) devices

3. Understand the complications of EF and PP devices

4. Demonstrate the ability to use the small battery drive

5. Demonstrate the ability to place K-wires across a fx

6. Demonstrate the ability to place a simple EF construct

PERCUTANEOUS PINNING OF FRACTURES

The most common fx using percutaneous pinning is the pediatric supracondylar humerus fracture (types II and III)

It is the most common operative procedure in pediatric fxs

Jan 2004 – Dec 2011 – 297 cases of the most severe type III SCH fx rx’ed at Riley

PEDIATRIC SCH FX

Type I – non displaced

Type II – posterior cortex intact

Type III – completely displaced

All type II and IIIs rx’ed with CRPP

TODAY – LEARN HOW TO PIN THE FX AFTER REDUCTION

Learn to use the battery driver

Understand K wire and Steinmann pin size

Understand the best mechanical configuration for CRPP

Understand the concerns for cross pinning

Demonstrate appropriate skill in pinning

K-WIRES AND STEINMANN PINS

Are the same , differentiated by sizeK wires – 0.028" (0.7mm) diameter

0.035" (0.9mm) diameter

0.045" (1.1mm) diameter

0.054" (1.4mm) diameter

0.062" (1.6mm) diameter

Steinmann pins – Range from 5/64” (2.0mm) to3/16” (4.8mm) in

increments of 1/64”

K-WIRES AND STEINMANN PINS

Trocar or diamond end

Smooth or threaded

Single or double

GENERAL CONCEPTS WITH PERCUTANEOUS FX PINNING

The drill is typically battery powered

Can use either quick release or Jacob’s chuck

For PP of fx using with smaller pins I recommend a quick release chuck

DRILL CHUCKS

Jacob’s chuck – the standard wood shop chuck using a key to tighten it

Quick release – the chuck grabs the wire by simply squeezing the handle

PLACE THE PIN IN THE CHUCK

With quick release make sure the number of “dots” is the appropriate one for the pin size selected

Assure the quick release is working properly and make sure it is powered before even starting the fixation!!!

START THE PIN FIXATION

Start perpendicular to the bone

When necessary, begin to angle the drill/wire after entering the bone – in a gradual manner

Do not bend the pin!

RADIOGRAPHIC ASSESSMENT

Start the pin under radiographic control to ensure appropriate direction

Monitor frequently - both AP and lateral

As you acquire more experience, the amount of imaging will become less

PIN CONFIGURATIONBiomechanically, cross pin fixation better

However it is associated with a significant increase in iatrogenic ulnar nerve injury – 1 in every 28 pts rx with cross pins will have an iatrogenic ulnar N injury!!

Multiple pins using lateral entry are clinically equal to cross pin configuration

Cross pinning should be used in only the most unstable situation!!!!

PIN CONFIGURATIONS

IDEAL PINNING

TYPE III SCH FXPerfect Pinning!

All pins parallel/divergent

All pins engage both cortices on both AP and lateral views

No cross pins!!

NUMBER OF PINS

For lateral entry pinning 3 is the typical number

However do not be afraid to use the blow gun technique – 4 or 5 pins

Remember that an iatrogenic ulnar N injury is a significant event!

AFTER FIXATION

Extend the elbow to assess the carrying angle / cubitus varus

Assess the stability of the fixation under real time flouroscopy with flexion / extension of the elbow

EXTERNAL FIXATOR - TIBIA

Today -• Identify the components in the large ex fix set• Review the steps for the assembly of a frame• Make sense of the “tinker toys”

EXTERNAL FIXATORIndications

TraumaOpen Fractures

Severe soft tissue injuryComminution

Bone loss

Temporizing or Definitive

DAMAGE CONTROL ORTHOPAEDICS

Applies to the polytraumatized patient

3 main stages• Early temporary stabilization of unstable

fxs, control of hemorrhage, and decompression intracranial lesion

• Resuscitation of pt in ICU and optimization• Delayed definitive management of fxs

DAMAGE CONTROL ORTHOPAEDICS

EXTERNAL FIXATOR Advantages

• Simplicity and ease of application

• Minimal blood loss

• Adjustability after surgery

• Access for wound management

EXTERNAL FIXATORDisadvantages

• Anatomic structures at risk (Safe Zones)

• Pin/Wire site infections

• Joint contractures

• Prolonged time to bony healing

EXTERNAL FIXATOR - TIBIA

Simple:• Clamps• Bars • Pins

TERMINOLOGY

Bars, Rods and Tubes are used interchangeably• bars & rods are solid• tubes are hollow

Pins & Schanz Screwssame

EX FIX CLAMPS

Connects pins to rods

EX FIX CLAMPS

Combination clamps – connects

• Pins to rods

• Rods to rods

EX FIX PINS/CLAMPS

Large clamps accommodate 4.0mm to 6.0mm Schanz Screws

4.0 mm for Small Ex Fix4.5 & 5.0 mm for tibia and pelvis6.0 mm for femur and large distractor

INSERTING PINS

Select site under flouroscopy

Small longitudinal incision

Hemostat down to bone

Then use the trocar and sleeves

Drilling and pin tract/insertion should be perpendicular to bone

SAFETY FACTORS

Pin/Wire should not

be in the fracture

When drilling go slow as not to burn the bone

STABILITY FACTORSPin/Wire Location

Maximal pin span

More pins distribute forces and increase construct stiffness

STABILITY FACTORS

Lower Bone-Rod distance increases

stiffness

In-line stacking

increases stiffness

Second sidebar at 90o to first increases

stiffness

STABILITY FACTORS

Pin/Wire SizeTorsional strength proportional to its

radius4

Pin core diameter <

1/3 bone diameter

STABILITY FACTORSInsertion Technique

Thread-Shank junctionis weakest point

Insert pin shank toproximal cortex

(2x increased stiffness)(threads = bone width)

Off plane pin insertion

INSERTING PINS

To insert pins:• Trocar & 2 sleeves• 3.5mm drill bit• Irrigate to prevent heat

& pin loosening !

Trocar3.5mm inner sleeve for

3.5mm drill bit5.0mm outer sleeve for

Schanz screw

INSERTING PINS

Chuck with T handle through outer sleeve

Advance to proper depth, just engaging opposite cortex – both a feel and radiographically confirmed

ADDING RODS/CLAMPS

Use 11mm cannulated socket wrench or ratchet wrench

Need 2 of each for surgeon and assistant

Then reduce fracture

- flouroscopic control

PIN CUTTERS AND PROTECTORS

Protects contralateral extremity and allows patient movement

SPANNING EXTERNAL FIXATORS

Portable Traction

Span intra-articular fracture

Aide reduction through

ligamentotaxis

THE END