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 This work is subject to copyright. All rights are reserved. whether the whole or part of the material is concerned. specifically the rights of translation, reprinting, re-use of illustrations, recitation, broadcasting. reproduction on microfilms or in other ways, and storage in data banks. Duplication of this publication or parts thereof is only permitted under the provisions of the German Copyright Law of September 9, 1965. in its version of June 24, 1985, and a copyright fee must always be paid. Violations fall under the prosecution act of the German Copyright Law. © Springer-Verlag Berlin Heidelberg 1974. 1982, and 1988 Softcover reprint of the hardcover 3rd edition 1988 The use of registered names, trademarks. etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. Product liability: The publisher can give no guarantee for information about drug dosage and application thereof contained in this book. In every individual case the respective user must check its accuracy by consulting other pharmaceutical literature. 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