Internal Fixation of Small Fractures: Technique Recommended by the AO-ASIF Group

394 Pages·1988·21.48 MB·English

by  Priv. Doz. Dr. Urs Heim

U. Heinl K.M. Pfeiffer
Internal Fixation
ofS mall Fractures
Technique Recommended by the AO-ASIF Group
Third Edition of Small Fragment Set Manual
In Collaboration with
1. Brennwald C. Geel R.P. Jakob T. Riiedi B. Simmen
H.U. SHiubli
Translated by T. C. T elger
With 258 Figures in more than 700 Separate Illustrations
Drawings by K Oberli
Springer-Verlag Berlin Heidelberg New York
London Paris Tokyo
PriV. Doz. Dr. URS HElM
Mattenstrasse 17 a
CH-3073 Giimligen-Bern
Prof. Dr. KARL M. PFEIFFER
Chirurgisches Departement
Kantonsspital Basel
CH-4031 Basel
Translated from the German by
TERRY C. TELGER
6112 Waco Way
Ft. Worth, TX 76133jUSA
ISBN-13: 978-3-642-72616-3 e-ISBN-13: 978-3-642-72614-9
DOl: 10.1007/978-3-642-72614-9
Library of Congress Cataloging-in-Publication Data. Heim, U., 1924-. [periphere Osteosynthesen. English] Internal fixation
of small fractures: technique recommanded by the AO-ASIF Group / U. Heim. K.M. Pfeiffer; in collaboration with J.
Brennwald ... let al.]; translated by T.C. Telger; drawings by K. Oberli. - 3rd ed. p. cm.
Rev. translation of: Periphere Osteosynthesen. First English edition published in 1974 under title: Small fragment set
manual. Bibliography: p.
Includes index. I. Internal fixation in fractures. I. Pfeiffer. K.M. (Karl Maria), 1927-. II. Brenn-
wald, J. III. Arbeitsgemeinschaft fiir Osteosynthesefragen. IV. Title. RDI03.I5H4413 1988617'. 15-dcl9 87-28711 CIP
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© Springer-Verlag Berlin Heidelberg 1974. 1982, and 1988
Softcover reprint of the hardcover 3rd edition 1988
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Reproduction of the figures: Gustav Dreher GmbH, Stuttgart
2124/3130-543210
Preface to the Third Edition
The second English-language edition of the Small Fragment Set Manual was
enthusiastically received and quickly went into a second printing.
In preparing a third edition, we found it necessary to revise the text extensively
and partly restructure it. The reasons for this are numerous.
Experience of recent years has brought technical refinements in the operative
treatment of many types of small fracture. Many of these changes stem from
the small-fragment-set training programs conducted in Switzerland since 1980,
and also from courses and symposia that have been held in other European
countries and the United States. These events were occasions for a fruitful ex
change of experience with surgeons who were critical of our methods. As a result
of this exchange, we perceived a need both to revise our indications and to
give greater attention to alternative techniques.
We also felt it necessary to respond to criticisms of the first two editions
concerning the catalog-like instrument lists and illustrations, and the attention
given to fundamental techniques. Many surgeons who work or would like to
work with small implants, especially those practicing abroad, are inexperienced
in operations on the larger bones. It is imperative that these colleagues be given
a basic introduction to the "biomechanical thinking" of the Swiss Association
for the Study of Internal Fixation (ASIF).
We have tried to place greater emphasis on soft-tissue techniques (incisions,
approaches, wound closure) and on potential dangers and errors that can occur
in specific situations. Clinical examples were added where necessary in order
to document new experiences. Also, previous descriptions were made more concise
so that we could expand the contents of the book while maintaining its compact
SIze.
The list of references, considered too general in the previous editions, has
been broken down by chapters for the present edition, although its length had
to be greatly curtailed. The dangers of this are well known. Also, some repetitions
are unavoidable when this type of arrangement is used.
A major goal of the third edition is to present innovations in our armamentar
ium that have been developed in the last few years or are about to be introduced.
We have tried to integrate and illustrate their practical use.
By consulting with qualified experts from the ASIF, we were able to add depth
and detail to specific chapters in cases where developments appeared to warrant
it. We are deeply indebted to these colleagues for their assistance.
Course organizers and authors of instructional materials are commonly blamed
for the failures of participants and readers. No type of teaching is immune,
whether it is given in courses, at the operating table, or in the literature. Yet
ultimately, every surgeon is responsible for acquiring his own experience and
expertise. Human inadequacies - including one's own - set painful limits to "pro
gress ", despite technical innovations.
v
As the age and situation of the authors make it unlikely that this material
will be reworked again at a later time, we must look upon this third edition
as the culmination of many years' work devoted to the study and description
of a specialized area of traumatology.
As before, we are indebted to many friends and colleagues for their help,
advice, and criticisms. We express special thanks to our illustrator, Mr. K. Oberli.
His superb drawings document his wealth of knowledge and his ability to grasp
this difficult material. We also thank Mr. V. Keller of the ASIF Documentation
Center in Bern for the excellent X-ray reproductions. We once again acknowledge
the tireless work of our secretaries, Mrs. M. Keller and Mrs. L. Gutzwiller,
and the efforts of others who quietly gave their help and council in the disposition
of many details. Finally, we thank the staff at Springer-Verlag for their thoughtful
cooperation and outstanding production work.
Giimligen and Basel, October 1987 V.HElM
K.M. PFEIFFER
VI
Contents
I. History and Goals . . . . . . . . . . . . . . . . . . . . .. 1
General Section
II. Implants and Instruments 5
1. Screws 5
2. Plates . 8
3. Additional Implants 10
4. The Small External Fixator 10
5. Instruments 10
6. Instrument Cases . . . . . 13
7. Mini Compressed Air Machine 13
III. General Techniques for the Internal Fixation
of Small Fractures 31
1. Basic Principles 31
2. Interfragmental Compression with Lag Screws 32
3. Tension-Band Wires .......... . 34
4. Axial Interfragmental Compression with a Plate 35
5. Neutralization Plates . . . . . . . . . . . . 37
6. Buttress Plates . . . . . . . . . . . . . . . 38
7. Combined Internal Fixation Using Small and Large
Implants ............ . 38
8. Multiple Fractures . . . . . . . . . 38
9. Operative Technique with Special Plates 39
10. Open Fractures ......... . 40
11. Small External Fixator - Technique and Indications 40
IV. Preoperative, Operative, and Postoperative
Guidelines . . . . . . . . . . . . . . ...... 69
V. Removal of Implants . . . . . . 73
VI. Autogenous Bone Grafts . . . . . . . . . . . . . . . . . . . 75
VII. Reconstructive Surgery . 77
VII
Special Section
VIII. Introduction and Overview . . . . . . . . 83
IX. The Shoulder Girdle 85
1. Clavicle . . . . 85
2. Scapula . . . . 87
3. Proximal Humerus 89
4. Illustrative Clinical X-Rays 89
X. The Elbow .... · 107
1. Distal Humerus 107
2. Radial Head . . · 109
3. Olecranon . . . · 112
4. Illustrative Clinical X-Rays 113
XI. The Shafts of the Radius and Ulna 139
XII. The Wrist and Carpus 145
1. Distal Radius 145
2. Distal Ulna 149
3. Scaphoid (Navicular) 149
4. Other Carpal Bones 150
5. Arthrodesis of the Wrist 151
6. Illustrative Clinical X-Rays 151
XIII. The Hand 179
A. Introduction 179
B. Injuries of the First Ray 180
1. Fractures of the Base of the First Metacarpal 180
2. Distal Fractures of the First Ray . . . 182
3. Secondary Operations on the First Ray 182
4. Illustrative Case Reports and X-Rays . · 183
C. Injuries of the Second through Fifth Rays .204
1. Approaches . . . . . . . . . . . . . .204
2. Fractures of the Second through Fifth Metacarpals .206
3. Articular Fractures . . . . . . . . . . . . . . .207
4. Fractures of the Phalangeal Shafts ...... . .208
5. Secondary Operations on the Second through Fifth Rays · 209
6. Fixation Techniques for Complex Injuries and Amputations of
the Hand ........... . · 210
7. Illustrative Case Reports and X-Rays .211
XIV. The Knee · 247
1. Patella · 247
2. Tibia . .248
VIII
3. Ligament Repairs ................ . 248
4. Lateral Avulsion Fractures (Femoral Condyle, Fibular Head) 249
5. Osteochondral Fractures ..... . 249
6. Secondary Operations . . . . . . . . 249
7. Illustrative Case Reports and X-Rays . 249
xv. The Tibial Shaft .259
XVI. The Ankle Joint · 261
A. Distal Intra-Articular Fractures of the Tibia . 261
1. Split Fractures without a Cancellous Bone Defect . 262
2. Simple Depressed Fracture ......... . 262
3. Complex Fractures with a Cancellous Bone Defect . 263
4. Secondary Operations . . . . . . . . 265
5. Illustrative Case Reports and X-Rays . 266
B. Malleolar Fractures . . . . . . . . . 286
1. Classification and Patient Selection . . 286
2. Internal Fixations and Ligament Repairs on the Lateral Side . 287
3. Internal Fixations on the Medial Side . . . . . . 295
4. Aftertreatment . . . . . . . . . . . . . . . . 296
5. Secondary Operations after Malleolar Fractures . 297
C. Fractures of the Talus .297
D. Illustrative Case Reports and X-Rays .297
XVII. The Foot . . · 337
1. Calcaneus · 337
2. Tarsal Navicular · 338
3. Cunei forms and Cubojd · 339
4. Dislocations and Fracture-Dislocations · 339
5. Fractures of the Metatarsal Shaft and Neck · 340
6. Fractures of the Fifth Metatarsal . . . · 341
7. Fractures of the Big Toe ..... . · 342
8. Secondary Operations on the Forefoot · 342
9. Illustrative Case Reports and X-Rays · 343
XVIII. Special Indications · 373
1. Internal Fixations in Children · 373
2. Use of the SFS in Rheumatoid Surgery · 373
3. Illustrative Case Reports and X-Rays · 373
References · 383
SUbject Index · 389
IX
List of Collaborators
Authors
Urs Heim, Priv.-Doz. Dr., Specialist in Surgery, Mattenstrasse 17 a,
CH-3073 Giimligen-Bern
Karl M. Pfeiffer, Prof. Dr., Chief of Hand Surgery, Kantonsspital Basel,
CH-4031 Basel
Collaborators
Jiirg Brennwald, Priv.-Doz., Staff Physician, Division of Hand Surgery,
Department of Surgery, Kantonsspital Basel, CH-4031 Basel and
Lab. f. Experimental Surgery, Schweiz. Forschungsinstitut, CH-7270 Davos-Platz
(Fixation Techniques for Complex Injuries and Amputations of the Hand)
ChristofGeel, Dr., Staff Physician, Department of Orthopedic Surgery, Upstate
Medical Center, 550 Harrison Street, Syracuse, New York 13202, USA
(Scapula)
Roland P. Jakob, Priv.-Doz., Assistant Director, Clinic for Orthopedics and
Surgery of the Musculoskeletal System, Inselspital Bern, CH-3010 Bern
(Small External Fixator)
Thomas Riiedi, Prof., Chief of Surgery, Surgical Clinic, Kantonsspital Chur,
CH-7000 Chur
(Scapula)
Beat Simmen, Dr., Staff Physician, Department of Surgery, Kantonsspital Basel,
CH-4031 Basel
(The Foot)
Hans-Ulrich Staubli, Dr., Chief of Surgery, Surgical Clinic, Tiefenauspital of
the City of Berne, CH-3006 Bern
(Distal Humerus)
lliustrator
Klaus Oberli, Technical Illustrator, Berchtoldstrasse 29, CH-3012 Bern
XI
I. History and Goals
Practical experience in the operative treatment the first surgeon to perform internal fixations
offractures quickly demonstrated a need to sup with small screws and plates. His results in 17
plement the stan~ard instrument set of the ASIF cases were published in 1958. Great hopes were
with smaller implants. Certain situations placed in the stable internal fixation of hand
pointed up obvious deficiencies in the instru fractures and the avoidance of postoperative
ments and appliances developed between 1958 casting, which can lead to joint stiffness if pro
and 1960. longed.
This first became apparent during the fixation In 1959 the AS IF developed the "scaphoid
of thin, narrow fragments in large cylindrical screw" for cancellous bone. Later it was modi
bones. The large drill holes jeopardized the via fied for more universal applications and was re
bility of the fragments, and the conical screw named the" small cancellous screw." In its new
heads threatened to crack them. The prominent, form, this implant is suitable for scaphoid frac
dome-like screw heads also proved troublesome tures only in highly selected cases. But the prob
on diaphyseal borders and in certain other ar lem of coping with the diverse shapes and di
eas. mensions of the peripheral bones could be
The relatively thick and inflexible plates of solved only by the creation of a complete instru
the standard set created unacceptably large for ment set having the widest possible range of
eign bodies on the metaphyses of the upper ex applications. The credit for developing this set
tremity and distal tibia. In these cases a gross belongs to Dr. Robert Mathys of Bettlach. The
disproportion existed between the bone and im first prototypes of small cortex screws with un
plant, and often this was detrimental to the soft threaded shanks produced excellent interfrag
tissues, especially the skin. mental compression, but they were extremely
Comminuted fractures involving smaller difficult to remove from the cortical bone. Then,
joints such as the elbow and ankle, in which in 1964, a standard set of small implants and
the long-term prognosis depends critically on instruments was assembled in rapid order and
an accurate reduction and fixation, were diffi made available for clinical testing.
cult to manage with bulky cancellous screws. The small fragment set of the ASIF (hereafter
It was usually necessary to resort to Kirschner abbreviated as SFS) was designed both in the
wires in these situations, with a corresponding realm and in the spirit of the Swiss watchmaking
sacrifice of rigidity. industry. All the instruments and implants of
Clinical experience and experimental studies the SFS are delicate, and they are designed to
have repeatedly shown that loose, isolated frag be handled with skill rather than force. While
ments of cortex will become revascularized if the screws are remarkably strong and provide
they can be stably reintegrated into a living envi excellent stability, they have their limitations.
ronment. This led to the use of small, individual It would be inappropriate to use them in areas
implants as components of a "combined" inter where mechanical or anatomic factors demand
nal fixation. the use of standard-size implants. The availabili
Finally, the standard-size implants were not ty of small implants should never tempt the sur
at all appropriate for the short, thin, tubular geon to compromise stability. In the past, many
bones of the hand and foot. In 1946 Kilbourne, failures of operative fracture treatment resulted
prompted by functional considerations, became from the use of implants that were too short
1