Presentation on theme: "PGY-1 CURRICULUM Basic Orthopaedic Skills"— Presentation transcript:
1PGY-1 CURRICULUM Basic Orthopaedic Skills Indiana University School MedicineDepartment of Orthopaedic SurgeryJuly, 2013
2GOALSUnderstand the indications for percutaneous pinning (PP) of fractures (fx)Understand the indications for damage control orthopaedics and stabilization with external fixation (EF) devicesUnderstand the complications of EF and PP devicesDemonstrate the ability to use the small battery driveDemonstrate the ability to place K-wires across a fxDemonstrate the ability to place a simple EF construct
3PERCUTANEOUS 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
4PEDIATRIC SCH FXType I – non displaced Type II – posterior cortex intact Type III – completely displaced All type II and IIIs rx’ed with CRPP
5TODAY – 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
6K-WIRES AND STEINMANN PINS Are the same , differentiated by sizeK wires – " (0.7mm) diameter0.035" (0.9mm) diameter0.045" (1.1mm) diameter0.054" (1.4mm) diameter0.062" (1.6mm) diameterSteinmann pins –Range from 5/64” (2.0mm) to3/16” (4.8mm) in increments of 1/64”
7K-WIRES AND STEINMANN PINS Trocar or diamond end Smooth or threaded Single or double
8GENERAL 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
9DRILL CHUCKSJacob’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
10PLACE 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!!!
11START THE PIN FIXATIONStart 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!
12RADIOGRAPHIC 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
13PIN CONFIGURATIONBiomechanically, 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!!!!
16TYPE III SCH FX Perfect Pinning! All pins parallel/divergent All pins engage both cortices on both AP and lateral views No cross pins!!
17NUMBER OF PINSFor 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!
18AFTER FIXATIONExtend 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
19EXTERNAL FIXATOR - TIBIA Today -Identify the components in the large ex fix setReview the steps for the assembly of a frameMake sense of the “tinker toys”
20EXTERNAL FIXATOR Indications Trauma Open Fractures Severe soft tissue injury Comminution Bone loss Temporizing or Definitive
21DAMAGE CONTROL ORTHOPAEDICS Applies to the polytraumatized patient3 main stagesEarly temporary stabilization of unstable fxs, control of hemorrhage, and decompression intracranial lesionResuscitation of pt in ICU and optimizationDelayed definitive management of fxs