In an External Fixation System, pins are inserted in the skin into the bone and held in place by an external frame. Thus, there is no placement of Orthopedic implants internally.
The usual indications are open fractures such as a tibia fracture which needs dressings or attention to a wound or flap. It can also be used with closed fractures, for example, unstable radius fracture.
External fixation is most successful in superficial bones, for example, the tibial shaft. Avoid it in deeper bones, e.g. the humerus or femur – here the chance of pin tract sepsis is greater. External Fixators are often used in the management of tibial fractures.
Indications for External Fixators:
- Bad soft tissue damage/ Severe open fractures
- Infected fractures
- For “Damage Control Orthopedics” (where the patient’s initial condition is too critical for prolonged surgery) to maintain length and provide stability. The affix is replaced by definitive fixation (IM pin or pate) once the patient stabilizes. A temporary exfix can be placed over the joint for plateau or pilon fractures that are length unstable. It is later removed when ORIF is performed, once soft tissue swelling subsides.
Advantages of External Fixation
- The method provides rigid fixation of the bones in cases in which other forms of immobilization, for one reason or another, are inaccurate. This is most common in open, severe II and III fractures in which traction or cast methods wouldn’t permit access for Management of the soft tissue wounds and in which dissection and exposure to orthopedic implant an internal fixation appliance would devitalize and contaminate larger areas and might significantly increase the risk of infection or loss of the limb itself.
- Neutralization, compression, or fixed distraction of the fracture fragment is possible with external fixation, as dictated by the fracture configuration. Uncomminuted transverse fractures can be optimally compressed, length can be maintained in comminuted fractures by pins in the major distal and proximal fragments (neutralization mode), or fixed distraction can be obtained in fractures with bone less in one of the paired bones, such as the ulna or radius, or in leg-lengthening procedures.
- The method allows direct surveillance of the limb and wound status, including wound healing, the viability of skin flaps, neurovascular status, and tense muscle compartments.
- Associated treatment, for example, skin grafting, dressing changes, bone grafting, and irrigation, is possible without disturbing the fracture alignment or fixation. Rigid external fixation allows simultaneous and aggressive treatment of bone and soft tissues.
- Immediate movement of the distal and proximal joints is allowed. This aids in the reduction of edema and nutrition of articular surfaces and retards capsular fibrosis, muscle atrophy, joint stiffening, and osteoporosis.
- The extremity is elevated without pressure on the posterior soft tissues. The orthopedic pins and frames can be suspended by ropes from overhead frames on the bed, relieving pressure on the posterior soft tissue part and aiding edema resolution.
- Early patient mobilization is allowed. With rigid fixation, the limb can be moved and positioned without fear of loss of fracture place. In uncomminuted, stable fractures early ambulation is often possible; this may not be the case if these fractures are treated by casting or traction. The use of external fixation also enables the mobilization of some patients with pelvic fractures.
- Insertion can be performed with the patient under local anesthesia if required. If the general medical condition of a patient is such that use of a spinal or general anesthetic is contraindicated, the fixator can be inserted using local anesthesia, although this is not optimal.
- Rigid fixation can be used in infected, non-unions or acute fractures. Rigid fixation of the bone fragments in infected fractures or in infected established nonunions is a critical factor in obliterating and controlling the infection. This is infrequently possible with traction or casting methods, and implantation of internal fixation devices is usually ill-advised. Modern external fixators in such instances can provide rigidity not afforded by other methods.
- Rigid fixation of infected, failed arthroplasties in which joint reconstruction is not possible and in which arthrodesis is desired can be achieved.
A thumb sprain is a severe condition that can occur in athletes, physically active people, or simply anyone who experiences an injury relating to their hand. Many would consider this as a minor injury that will gradually heal on its own when, in fact, a thumb sprain can affect your ability to grasp, therefore impairing the functionality of the affected hand. So, it is necessary to consult a doctor, who will examine and treat you in time using orthopedic instruments, procured from reputed orthopedic instrument Manufacturer.
The main ligament that controls the function of your thumb is called the ulnar collateral ligament, spanning between the index finger and thumb. During a fall, instinctively one extends his arm to catch oneself, therefore causing the hand to bear most of the impact. This is the most common reason for thumb sprains, as the impact from a fall can cause an extensive tearing or stretching of the ulnar collateral ligament.
Skiers are usually most susceptible to severe thumb sprains, a condition also known as “skier’s thumb”. When a fall occurs in the process of skiing, the ski pole creates extra stress on the thumb ligament and increases the chances of a tear. Contact, ball sports, racket are other activities where the thumb is at risk of a sprain because of trauma such as a sudden hit or a fall.
Thumb sprains are among the toughest conditions to self-diagnose, as the onset of pain may not be immediate. Other symptoms may include swelling, tenderness, or bruising. If you experience any type of thumb injury, it is important to visit an orthopedic specialist whether you notice any symptoms or not, as leaving a sprain untreated may lead to complications in the thumb function.
When the ligament is partially torn your thumb will need to be immobilized with a splint or cast for approximately 4-6 weeks until the thumb regains its full stability. When the ligament is fully torn and/or there is any sign of bone fracture, you will need surgery followed by a recovery period of 6-8 weeks. The surgery is performed by the orthopedic surgeons using various instruments accessible from top orthopedic implant companies in India.
A bone plate may be placed so that it may be utilized for one of the following kinds of structural support:
- Compression Mode
- Neutralization Mode
- Buttress plate
- Antiglide plate
- Bridge plating or span plating
- Tension band
Plates are available in various shapes and sizes depending on the bone size and its anatomical shape. Similarly, Bone Screw size is dependent on the size & type of plate used. A small plate will typically be used for a small bone, which allows space only for the screw of smaller size.
Depending upon the fracture type and location, a plate can be used in any one of the following methods
The word compression in fixation of a fracture means bringing the two fragments closer to one another so that the fragments oppose well.
When the plate is utilized to achieve compression with the fracture fixation, it is said to be utilized in compression mode. This mode is utilized on oblique and transverse fractures.
In this kind of plating, a lag screw is utilized to neutralize shear, bending and rotational forces. The goal of this kind of plating is not to attain compression (this has already been attained by the lag screw).
This type of plating is also utilized as an adjunct where bone screws are used alone in long bones an accurate reconstruction with interfragmentary compression can be attained, but screws are not strong in resisting twisting or bending forces. Addition of a bone plate offers further resistance to such forces.
The fibular fracture normally seen in ankle injuries is usually fixed with lag screws protected by a neutralization plate.
The orthopedic plate is put on the tensile surface of the bone, but it is not pre-bent.
A buttress is an architectural structure built against or projecting from a wall which helps to reinforce or support the wall.
A buttress plate is utilized to prevent collapse in fracture patterns which are unstable under compressive forces.
A buttress plate is very thin in comparison to compression plate and is usually applied on the compressive surface of the bone.
This is the most commonly used plates around joints.
Here there is a comparatively soft cancellous bone core enclosed by a thin layer of cortical bone. Correct osteosynthesis may be attained by lag screws alone but under load, there may be a risk of screws cutting out of the bone or bending.
The addition of a bone plate will prevent such deformity under axial load. The plate should be located where the maximum load is predicted to be. Proximal tibia, for example, plates may be needed on one side or another to protect a fixation of tibial plateau fracture.
For the most common anatomical buttressing needs, there are specially shaped plates.
In antiglide plating, the plate is fixed to the bone in such a manner that it prevents the distal fragment from overriding when force is applied along the long bone axis.
The distal fragment is firmly impacted between the plate and the fracture surface of the proximal plane.
This principle is generally applied in distal fibula fracture. It can be termed as a variation of compression plating.
Basic Principles and Techniques of Plate Fixation – Excellent results of fractured bones by plate and screws can be achieved not only by following biomechanical principles but also depends on the quality and design of plate, screw, and bone health.
Various Factors Can Be Responsible for Good Results.
Plate material should be adequate in its strength. The strength of the plate varies with the cube of the thickness of the material. Titanium material’s plate stiffness is less than steel. Moreover, the very stiff plate can weaken the bone after fracture healing is complete. Hence, titanium has a distinct advantage over stainless steel.
The contact surface of the plate also has an important role in the excellent results. Conventional plate due to larger contactareahampers the underneath blood supply of bone leading into immediate post-fixation osteoporosis.
Based on the Above Observations the Need for New Design Was Felt.
To minimize the surface contact area substantial material is removed from the undersurface of the plate between the screw holes. This arched appearance has the following distinct advantages over the conventional plates.
A: = It reduces the stiffness of the plate to the same level as that of the screw hole area Resulting in less chance of breakage as compared to conventional plates.
B: = Since it has uniform stiffness throughout the plate in spite of holes. The newer Designed plates can be contoured in a continuous curvature. It evenly distributes the Bending and torsional stresses over a long segment along with the plate. Moreover, the Screw head has a good fit despite the bending of the plate. Also, the even distribution of holes in a Long length plate prolongs the fatigue life of the plate.
C: = The design of plate holes also contributes to the longevity and modularity of the Implant. Plate holes are distributed evenly and symmetrically along with the plate with Oblique undercuts on the inner side of the plate.
Undercut allows the unhindered inclination of lag screw up to 40 degrees Longitudinally and 7 degrees in the transverse plane. A proper compression across the fracture can be achieved through plate holes with the modularity of bi-directional Screws.
One more advantage of even distribution of holes is that in case of an exchange or Revision surgery of plates, the longer plate can be used without conflicting with Previously drilled holes.
As regards the surgeon’s factor, proper exposure of fracture, good surgical Technique, and choosing the proper length of the ortho implant (plate) also contributes to the excellent Final result. Choosing the short implant (plate) will make the construct unstable while Too long an implant (plate) will cause unnecessary damage to soft tissues and prolongs the operating time as well.
The wrist contains two forearm bones: the ulna and the radius. The most commonly encountered fracture in the wrist is that of the distal radius, the end of the larger of the two arm bones at the thumb-side of the wrist. Generally, Distal radius fractures occur about one inch from the end of the radius and are caused due to injury when one falls on an outstretched hand or if one has osteoporosis or low bone density. The injury causes swelling, pain, and bruising and can create a deformed appearance to the wrist.
The length of time for recovery differs greatly between patients. It is essential to have your recovery guided by your physician and a certified hand therapist. It is necessary to keep the wrist elevated and to keep the fingers moving by making a tight fist as often as possible. There is no reason to use a squeeze ball. An empty fist is the best. It is very common to have swelling and stiffness in the fingers and hand for quite some time after a wrist fracture.
Stable fractures that do not affect the joint alignment are treated without surgery. Initial treatment generally includes elevating the arm, icing, and anti-inflammatory medications to control swelling and pain. A splint may be used for 1 to 3 weeks to allow for swelling. After the swelling is subsided, the splint will be replaced by a fiberglass cast. After the injury, the wrist is typically immobilized for as many as 6 weeks. A sling may be worn for comfort, but it is important to work on maintaining a full range of movement of the elbow and shoulder to prevent stiffness. Regaining range of motion of the forearm and wrist is the focus for the first few months, followed by strengthening. In most cases, a return to sports may be expected no before 3 months from the start of treatment. After the cast is taken off, a removable splint can be worn either for strenuous or full-time activities until the fracture is fully healed.
For more serious fractures, surgery may be needed to correct the alignment of the bone. Sometimes a cast alone can be used, or it may be essential to insert metal pins, bone screws and an orthopedic plate.
Another common fracture is of the scaphoid bone which is a small bone in the thumb-side of the wrist. It is a common sports injury and is often a result of a fall toward an outstretched arm.
Treatment depends on the location of the break. Fractures at the end of the bone, close to the thumb, often heal in a few weeks when placed in a cast. If the scaphoid is broken in the middle of the bone or closer to the forearm, healing can be more difficult and need a long-arm cast or surgery.
When the scaphoid is broken at the proximal pole or waist, surgery may also be recommended. For surgery locking hand plates require that can be accessed from the top orthopedic implant manufacturers in India. Wires and bone screws are used to stabilize the bone, so it can heal properly. After surgery, the wrist may be put into a cast, however, even with surgery, these fractures can be hard to heal.
What is a Hip Fracture?
A hip fracture is a severe injury that may hamper your ability to walk. Most people fracture their hips at the upper area of the femur, where the thighbone meets the hip joint. The injury usually requires surgery and physical therapy for a full recovery. The surgeons use ortho implants and orthopedic tools in the surgical procedure.
Hip Fracture Treatments
A fractured hip is a far more serious injury than just any broken bone. A hip fracture, especially in the old age, can greatly hinder the quality of life. If you suspect you have fractured your hip, the best thing to do is to take immediate medical treatment.
When to Seek Medical Attention
While women over the age of 65 are at the highest risk, anyone can suffer a fracture of the hip. If you have any of the following symptoms, you must consult an Orthopedic Specialist at once.
- Severe pain from the hip or groin area- Swelling or inflammation in the hip
- Bruising- Unable to put pressure or weight on the leg
- If you have recently suffered an accident or fall and are experiencing any of these symptoms, seek immediate medical attention.
Do I Need Surgery?
In most cases, surgery is the best way to fix a fractured hip with the help of orthopedic Hip implants. If you are in stable medical condition, most surgeons will want to operate 8 to 24 hours after you have arrived at the hospital. Delaying further will only add to your suffering and pain and increase the chance for complications and infections.
What to Expect if you Need Hip Surgery?
When you first go to the hospital, your doctor will most likely need to do some imaging test to confirm the diagnosis. This could mean either computed tomography (CT) scan or magnetic resonance imaging (MRI).
After you are properly diagnosed, your doctor will schedule surgery as soon as possible. If you have any other health problems, your doctor might delay your procedure and wait until you are in stable enough medical condition for hip surgery.
Recovery After Hip Surgery
After your surgery, your physician will work with you to customize a recovery plan that fulfills your needs. Every patient is different and there recovering pace too. In most cases, you will stay in the hospital for around 4 days before being discharged to initiate your physical therapy. A rehab program is vital and reduces the need for a walker or cane.
The most important thing to remember after your surgery is to be patient. Recovery can be a challenging and long effort and could take as long as a year. Even then, some patients may never be able to move around as they could before their hip fracture. The best thing is to keep a positive outlook and not be discouraged.
Who at a Risk of a Broken Hip?
While anyone can break their hip, these fractures are more common among women and old people, because of decreased bone density and length. Here are some more aspects that put one at greater risk of fracturing their hip:
- Heredity: If your family members typically have a thin, tall frame or if any of them have fractured their hips before.
- Lack of activity: Those who do not get enough exercise that bears weight on their hips (even something as simple as walking) may not have strong hip bones.
- Improper nutrition: Vitamin D and calcium help our bones grow strong. Diets that do not have these components may result in weak bones.
- Arthritis: Those with arthritis typically have weakened bones, putting them at higher risk of a hip fracture.
- Other medical conditions: Any conditions that cause problems with balance or dizziness may put one at greater risk of falling, which can result in a broken hip.
Stress fractures are a type of overuse injury characterized by small cracks in the bone. When muscles are fatigued and can’t absorb repeated impact, the shock is transferred to the bones. Weak bones caused by Osteoporosis may also be more vulnerable to stress fractures. These fractures can occur from sports or normal daily activities.
Stress fractures mostly occur in the bones of the lower leg and foot. The second or third long bones between the mid-foot and toes are the most often effected. Stress fractures sometimes appear in the heel, on the top of the foot, the outer bone of the lower and the navicular.
One of the most common occurrences of stress fractures occurs in runners who have been confined indoors during an off season and then, return to running without proper conditioning.
Improper foot gear is another reason due to which athletes get stress fractures. A well-known and old shoe can alter the dynamics of the foot and contribute to stress fractures. Athletes that change surfaces, like going from a grass tennis court to a hard court, can increase their risk for stress fractures, or from an outdoor running track to an indoor track. Other conditions, such as flatfoot or bunions, can alter the mechanics of the foot making it more vulnerable to stress fractures.
Symptoms of Stress Fractures
- Pain that develops slowly and is relieved with rest
- Swelling on top of the outside the ankle or foot
- Possible bruising
Treatment of stress fractures
Most stress fractures will heal if activity level is decreased and protective footwear is worn for two to four weeks. A stiff-soled shoe, a removable leg brace shoe, or sandal may be needed to provide support. Athletes are often advised to switch to a sport that puts less stress on the leg and foot while the bone heals, such as bicycle riding and swimming.
For stress fractures in the outer side of the foot or in the talus or navicular bones that take longer to heal, a cast may be applied to the foot or the use of crutches may be recommended until the bone heals. In some cases, surgery may be essential. The orthopedist may insert a bone screw into the bone to ensure proper healing. The orthopedic implants such as bone screws, etc. can be accessible from the orthopaedic implant manufacturer.
The components of a ring fixator system are categorized into 2 categories: main and secondary. The main parts are the standard elements utilized to correct skeletal deformities: rings, wire-fixation bolts, wires, and buckles, pin clamps, and pins.
The secondary parts of the system comprised of the elements essential for the assembly of the fixator: rods, plates, posts, supports, hinges, washers, bushings, sockets, nuts and bolts. To assemble the several pieces of equipment various kinds of wrenches and wire tensioner are required. There are no screws in this system and screwdrivers aren’t required.
A ring with multiple holes and a flat surface is the main component of a circular external fixator (Ilizarov).
The ring encloses a limb segment: 2 or more rings are connected to make a frame. The ring’s flat surface supports the heads of the nuts and bolts. The surface-nut interface or surface -bolt guarantees firm fixation of the wires, threaded rods, and bolts while treatment. The flat surface of the rings is essential for attaining a secure wire inclination and plane orientation. All rings in a frame are aligned perpendicular to bone’s long axis. A ring is made of carbon fiber or stainless steel provides strong support for the frame and is intended to bear high stresses of the tensioned wire, up to 150 kg. The ring’s internal diameter measures from 80 to 240 mm. A whole set has rings of 12 different diameters to suit several limb thicknesses.
A ring fixator set has several half and full rings. A full ring is lighter, has more holes than 2 connected half-rings, and doesn’t need connecting bolts and nuts. The holes in the ring are utilized for introduction of a threaded rod, a connector plate or a hinge. On the negative side, a full ring must be placed before the introduction of wires. If clinical state demands the removal of a full ring during the treatment tenure, then it must be cut with specific instruments.
Every half-ring, depending on its size, has eighteen to twenty-eight holes in the mid-segment of the flat surface. The standard holes are equally distance threaded (4 mm apart) and are of same size (8 mm in diameter). Threaded rods or bolts are affixed in the holes. 2 half-rings are joined by bolts and nuts to make a full ring. The ends of the plate don’t have standard-sized hole, are offset as well as ledged to fit together on an even plane to form a full ring.
The half-rings may also be connected to make an oval ring, three- and four-leaf clover rings and another specialized construct with the help of additional devices to make more space between the ring and the limb.
A five-eighths ring enables joint motion and is usually deployed near knee and elbow joints. Besides motion, these rings enable the introduction of cross wires, a distinct benefit near these joints. This ring can be used in the middle of a regular frame to offer access for management of soft tissue. Though, 5/8 ring is weaker than a full ring; a three-point connection to a full ring reinforces as well as strengthen it. Wires attached to a 5/8 rings are tensioned only after such stable connection is established. These rings can be accessible in three sizes from 130 to 160 mm.
From the mechanical viewpoint, it’s not essential to remove an orthopaedic nail in a weight-bearing limb and dissimilar from a plate, it can be left indefinitely in the body. Removal initiated by the request of the patient should be delayed for eighteen months. Intramedullary devices sometimes induce local changes that can be irritative either to the bone or to the patient and require removal. Swelling and local pain secondary to backing out of the implant is another indication for removal; confirmed bone union on radiological examination is a prerequisite for such removal.
A sharp-angled deformation seeming in the follow-up roentgenogram is an indication of appliance failure. A sharply bent device is necessary to be removed and replaced as it has undertaken plastic deformation and is expected to fail with further weight-bearing. Bent nails may be removed forcefully straightening and extraction.
Nail removal shouldn’t be undertaken lightly. Specialized extraction equipment fitting the exact nail must be available. Although removal is often a straightforward process, mismatching equipment, nail breakage, damage to the threads in the proximal end of the nail and distortion in the bony anatomy preventing removal are common causes of difficulty.
Difficult situations in nail removal
- The extraction hook fails to grasp.
- Stack the canal round the hook with ball-tipped guide wires. Hold the bunch in a vice grip and hammer out to remove the nail.
- Bone growth along the track of the locking bone screws removed some time ago.
- Re-drill the holes with an appropriately large drill bit.
- The broken nail in a united fracture; the extraction hook fails to regulate the alignment as well as pulls the nail tight against the opposite cortex rather than out of the canal.
- Take away the proximal half of the nail. Pass a guidewire that is ball-tipped into the proximal canal till the ball is near the broken end of the nail. Ream the proximal canal up to the nail’s broken end to facilitate easy removal. Pass 2 or more guidewires into the distal nail fragment and impact them with a hammer. Grasp the bunch in a vice grip as well as hammer out to remove the nail.
- The broken solid nail in an ununited fracture.
- Take away the proximal half. Create a window in the bone distal to the tip of the nail as well as hammer the nail out. In the femur, arthrotomy of the knee joint can be needed. In the tibia, if the nail is short, make an opening in the medial malleolus to arrive till the nail.
- The protruding nail in a healed fracture and nail doesn’t move.
- Use specialized metal cutting equipment to remove the offending nail length.
- Impacted nail.
- Find the point of maximum hold under fluoroscopy. Create a longitudinal cut in the bone with the help of an oscillating saw or an osteotome at that point. Extend the cut either way till the bone springs open enough to allow removal of the nail. The method is suited best for a tibial nail and is employed only as a final resort.
Full weight-bearing may start immediately after the removal of an intramedullary nail, but a coming back to vigorous sporting activity should be delayed until rehabilitation is attained.
Pins are versatile and are usually helpful for internal fixation. A pin has a comparatively small diameter and is inserted through the soft tissue and bone with comparatively little trauma. A Kirschner wire is inserted with a power drill as well as a guidance system. The soft tissues tend to wind round the Kirschner wire at the time of insertion and must always be protected. Several types of guides are in use: a telescoping guide linked to the drill, or an external guide with a handle are common orthopedic Instruments. A power drill with a quick locking and release mechanism save considerable time and is also suitable for insertion of Kirschner wire from the barrel of the drill, that doubles as a guide.
Kirschner wire insertion
- Always deploy a power drill to insert a Kirschner wire.
The wire bends once it’s inserted on a hand drill.
- To protect soft tissues during insertion, always use a guide to direct the pin.
- Support the wire.
- Place the cutter jaws at right angles to the wire.
- Bend the wire up after cutting.
- Tip of wire must not touch the plaster cast.
Fashion a point- 2 oblique cuts to fabricate a sharp tip
Kirschner wires are helpful for provisional fixation of a comminuted fracture. They help in accurate placement of the fragments and orthopedic implants, especially the plates and the bone screws. Multiple wires are inserted without any added trauma. When provisional stability has been attained, X-ray pictures can be made to visualize the strength as well as weakness of the construct.
Planning is necessary while inserting Kirschner wires for provisional fixation. Pins are introduced in such a way that they don’t obstruct the final placement of the definitive implants. For instance, wires are passed parallel to each other in the same direction in which the lag screw is to be introduced in order that there’s no obstruction to compression of the fracture with the lag screw.
Whenever a Kirschner wire is used for definitive fixation, the pin’s end should be cut a centimeter under the skin and may be bent; a long wire end will protrude through the skin, either because of the pressure from within or from outside. If a wire is cut too near the bone, it’s difficult to locate it at the time of removal. The jaws of a wire cutter are always positioned at right angles to the wire. If they’re positioned at any other angle, a twisting force develops whereas snapping the wire. This force is transferred to the bone and due to this unintentional fracture may occur in a small bone, specifically in the cancellous area. A sharp point at the pin trip may be fabricated by making an oblique cut and then rotating the pin to make the 2nd oblique cut. The free end of the wire must always be bent with an orthopedic instrument. The bending force, if transmitted to the bone, may cause an inadvertent fracture; this complication is avoided by gripping and stabilizing the pin at the time of bending. There’s a genuine danger of migration of a straight pin into the soft tissues or into the bone; a pin is known to travel a long distance across the planes of soft tissue. When using a pin around the shoulder, it’s imperative that the trip be bent.
A pin enclosed in a plaster cast shouldn’t touch the cast but move freely inside. There’s considerable movement between the cast and the bone because of the presence and the thickness of the soft tissues. If any pin touches the plaster, forces are transferred to the bone, resulting in pin loosening as well as loss of fixation. A pin must be removed after it has served its purpose.