PGY-1 CURRICULUM
Basic 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 size
K 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 CONFIGURATION
Biomechanically, 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 FX
Perfect 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 FIXATOR
Indications
Trauma
Open Fractures
Severe soft tissue
injury
Comminution
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 FIXATOR
Disadvantages
• 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 Screws
same
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 Fix
4.5 & 5.0 mm for tibia and pelvis
6.0 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 FACTORS
Pin/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 Size
Torsional strength
proportional to its
radius4
Pin core diameter
<
1/3 bone diameter
STABILITY FACTORS
Insertion Technique
Thread-Shank junction
is weakest point
Insert pin shank to
proximal 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 !
Trocar
3.5mm inner sleeve for
3.5mm drill bit
5.0mm 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