Manual of Internal Fixation: Technique Recommended by the AO-Group Swiss Association for the Study of Internal Fixation: ASIF

292 Pages·1970·18.34 MB·English

by  M. E. Müller M.D.

Manualof
Internal Fixation
Technique Recommended by the AO-Group
Swiss Association far the Study of Internal Fixation: ASIF
By M. E. Müller
M. Allgöwer . H. Willenegger
In Collaboration with
W. Bandi· H. R. Bloch· A. Mumenthaler
R. Schneider· B. G. Weber and S. Weller
J.
Translated by Schatzker
With 306 Figures
Springer-Verlag
Berlin . Heidelberg . New Y ork 1970
ISBN-I3: 978-3-642-96067-3 e-ISBN -13: 978-3-642-96065-9
DOI: 10.1007/978-3-642-96065-9
Translation of MÜLLER / ALLGÖWER / WILLENEGGER, Manual der Osteosynthese (1969)
This work is subject to copyright. All rights are reserved, \.vhether the whole Of part of thc material is
concerned, specifically those of translation, reprinting, re-use of illustrations, broadcasting, reproduction
by photocopying machine or similar means, and storage in data banks.
Under § 54 of the German Copyright Law where copies are made far other than private use, a fee is payable
to the publisher, the amount of the fee to be determined by agreement with the publisher.
© by Springer-Verlag, Berlin . Heidelbcrg 1970. Library of Congress Catalog Card
Softcover reprint of the hardcover 1s t edition 1970
~umber 76-138812
The use of general descriptive names, tradc names, tradc marks, etc. in this publication, even if the former
are not especially identified, is not be taken as a sign that such namcs, as understood by the Trade Marks
and Merchandise Marks act, may accordingly be uscd frcely by anyone.
Universitätsdruckerei H. Stürtz AG Würz burg
Preface
The German edition of our book entitled "Operative Frakturen
behandlung" by M. E. MÜLLER, M. ALLGÖWER and H. WILLENEGGER
(Springer, Berlin . Göttingen . Heidelberg, 1963) has been out
of print now for more than three years. We are planning a
new edition which will deal with the collective experience
of 14,000 new cases, all treated by internal fixation, and will
include the newest developments in the field of internal fixa
tion. However, it will be some time before this new edition can
be published. Increasing demands for a description of the AO
technique of internal fixation has stimulated us to publish this
manual. In it we shall describe in a comprehensive but somewhat
apodictic mann er the principles and techniques of the AO methods
of fracture treatment and reconstructive surgery, which in our
hands, have stood the test of time.
The book is written in a somewhat abbreviated style. It cor
responds in subject matter to the teaching given at the AO courses
in Davos, but deals with each subject more thoroughly.
We have dispensed with pictures of the instruments, as these may
*.
be found in the Synthes Catalogue
This manual should be regarded as the product of collective
experiencc, containing new thoughts and new discoveries from
basic research.
In considering the risks of mistakes and dangers, we can only
reiterate what we have already stated in "Technique of Internal
Fixation of Fractures": "Open treatment of fractures is a valuable
but difficult method which involves much responsibility. \"'Ve
cannot advise too strongly against internal fixation if it is carried
out by an inadequately trained surgeon, and in the absence of full
equipment and sterile operating room conditions. Using our
methods, enthusiasts who lack self criticism are much more
dangerous than skeptics or outright opponents. We hope there
fore that readers will understand our efforts in this direction and
that they will pass on any constructive criticism to us".
*
Catalogues can be obtained from distributors all over the world, or from the
manufacturers, Synthes, CH-4437 Waldenburg (Switzerland).
v
We must reeord our deep appreciation to our publishers as weIl
as to our eollaborators. Our gratitude is also due to the artist,
Mr. OBERLI, who drew most of the illustrations and to Miss
DAXWANGER, who prepared them for publieation.
M. E. MÜLLER
M. ALLGÖWER
Berne, Oetober, 1970 H. WILLENEGGER
VI
Table of Contents
General Considerations
1. The Aims and the Fundamental Principles of the AO Method 1
A. Thc Aims of the AO Method . . . 2
B. Basic Principles . . . . . . . . . 6
1. Reaction of Bone to Metal Implants 6
2. Clinical and Empirical Findings in Internal Fixation with
Compression . . . . . . . . . . . . . . . . . . . . .. 8
3. The Histology of Bone Union Occurring under Compression. . 10
4. The Biomechanical Experiments for Measuring the Magni-
tude and Duration of Compression between Fragments. . . . 12
S. Thc Dcvelopment of Standard Bone Instrument Sets which
Have Made it Possible to Overcome most of the Problems of
Internal Fixation of Fresh Fractures, Pseudarthroses, Osteo-
tomies and Arthrodeses . . . 14
6. The AO Documentation Center. . . 16
11. The Internal Fixation-Method of the AO 19
A. Compression . . . . . . . 19
1. Interfragmental Compression 20
2. Axial Compression. . . . . 32
3. Interfragmental and Axial Compression Combined with Either
the Neutralization or Buttress Plate . . . . . . S3
4. Angled Blade Plates as Means of Internal Fixation 6S
B. Intramedullary Methods of Internal Fixation 80
In. Pre-operative, Operative and Post-operative Guide-Lines 93
Post-operative Care. . . . 94
Post-operative Positioning . 96
Autogenous Bone Grafts 98
IV. Implants. . . . 100
A. The Removal . . 100
B. Fatigue Fractures 102
VII
Special Part
Internal Fixation of Fresh Fractures
Introduction . . . . . . . . . 107
1. Closed Fractures in the Adult 111
A. Fractures of the Scapula . 111
B. Fractures of the Clavicle . 111
C. Fractures of the Humerus . 114
D. Fractures of the Forearm . 127
E. Fractures of the Acetabulum 139
F. Fractures of the Femoral Neck 147
G. Fractures of the Femoral Shaft 164
H. Fractures of the Patella . 175
J. Fractures of the Tibia 178
K. Malleolar Fractures 193
II. Compound Fractures in the Adult 211
III. Fractures in Children . . . . . 221
Supplement
Reconstructive Bone Surgery. By M. E. MÜLLER
Introduction . . . 235
1. Pseudarthroses 237
II. Osteotomies 261
A. Osteotomies in the Upper Extremity 262
B. Intertrochanteric Osteotomies. . . 264
C. Femoral Shaft Osteotomy through Old Fracture Callus . 268
D. Supracondylar Osteotomies. . . 270
E. Osteotomy of the Proximal Tibia . . . . 272
F. Osteotomy of the Tibial Shaft. . . . . . 274
G. Osteotomy of the Lower End of the Tibia 276
II1. Arthrodeses . . . . . . . . . . . . . 278
A. Shoulder Arthrodesis. . . . . . . . . . 278
B. Technique of Arthrodesis of the Elbow and Wrist Joint 280
C. Hip Arthrodesis with the Cobra Head Plate . . . . 282
D. The Technique in Arthrodesis of the Knee . . . . 284
E. Technique of Compression Arthrodesis of the Ankle 286
References . . 290
Subject Index. 293
VIII
Authors: M. E. MCLLER,
M.D., Professor of Orthopaedic Surgery,
University of Berne Medical School,
Director of the Dept. of Orthopacdics,
University of Berne, Inselspital, CH-3008 Bern
.M. ALLGÖWER,
M.D., Professor of Surgery,
University of Basle Medical School,
Director of the Dept. of Surgery,
University oE BasIe, Bürgerspital, CH-4000 Basel
H. \V'ILUXEGGER,
M.D., Associate Professor oE Surgery,
University oE Basle Medical School,
Surgeon-in-Chief, Dept. oE Surgery,
Kantonsspital, CH- 4410 Liestal
Contributors: \V'. B\:--;DI,
;\LD., Surgeon-in-Chief,
Dept. oE Surgery, Bezirksspital,
CH-3800 Interlaken
H. R. BLOCH,
::\:I.D., Surgeon-in-Chief,
Dept. oE Surgery, Kantonsspital,
CH-8750 Glarus
A. J\;IclIE:--;TIHLER,
::\:I.D., Bezirksspital, CH-4900 Langenthai
R. SCH}.iEIDER,
::\:I.D., Surgeon-in-ChieE,
Dept. of Surgery, Bezirksspital,
CH-3S06 Großhöchstetten
B. G. \V'EBER,
M.D., Surgeon-in-Chief,
Dept. oE Orthopaedics and Traumatology,
Kantonsspital, CH-9000 St. Gallen
S. \V'ELLER,
::\:I.D., Professor oE Surgery, Surgeon-in-Chief of
Berufsgenossenschaftliehe Unfallklinik
D-7400 Tübingen
Translator : ]OSEPH SCHATZKER, ::\:I.D., B.Sc. (::\:Ied.), F.R.C.S.(C),
University of Toronto, Ontario, Canada
IX
General Considerations
The Aims and the Fundamental Principles
I.
of the A 0 Method
The chief aiJll in jraclttre treatment is the retum oj the itgz(red limb to juli activitJ!. In order to prevent
malunion, joint stiffness and soft tissue damage resulting from circulatory disturbances which
have become known as "fracture disease," wc aim to achieve such rigid intemal fixation that
a long period in pIaster is no longer necessary, and early active joint movement is possible.
These principles also apply in elective bone surgery, as the threat of pseudarthrosis has been
overcome. It is also possible to shorten the period of time in hospital, and to facilitate earlier
weight bearing and a rapid return to work. Our experience has taught us that really rigid
internal fixation is best obtained by using cOJllpressioll techniques and intrallledullary nailing.
The value of compression in obtaining rigid internal fixation was recognized by Ln1BoTTE,
DANIS, KROMPECHER, EGGER, CHARNLEY and many others, long before the foundation of
our association (AO). The work of these investigators are the pillars on which we have built
the AO method. Clinical experience, histological studies and biomechanical experiments in
animals, the development of standard instrument sets, and the founding of a documentation
center, have all contributed in enahling us to assess the results of ca ses operated upon, using
compression techniques.
In the next few pages we will show by means of two examples how early mobilization can
be achieved. Later wc will describe briefly the six basic principles of the AO method.
1
A. The Aims of the AO Method
The chief aim of the AO method is the earb retNrn to Ju!! Junetion of the injured limb
This is achieved by:
l
J
Aeeurate anatomieal reduetion. This is of Rigid interna! fixation.
particular importance in intra-articular
fractures.
I
I
Atraumatic operative technique preserv- Avoidanee oJ soft tissue damage and the so-
ing the vitali~y of bone and soft tissues. called "fracture disease". This is accom
plished by early, active, pain-free mobili
zation of the muscles and joints adjacent
to the fracture, without interfering with
bone union.
These Jour biomechanical prineip!es are vita! to a method oJ interna! fixation to produee optima!
{raeture healing.
In multiple fractures one must aim to mobilize all joints early. Example:
Fig.l
a Patient with a comminuted fracture of the left femur (a'), supracondylar fracture of
the right femur (a"), and a compound fracture of the left tibia (a"').
b Function four weeks after operative treatment. Normal function of hip, knee and
foot. The legs are symmetrical and partial weight bearing is possible.
c Four months after internal fixation using condylar plates.
2