1. PGY-1 CURRICULUM Basic Orthopaedic Skills
Indiana University School Medicine
Department of Orthopaedic Surgery
July, 2013

2. GOALS
Understand the indications for percutaneous pinning (PP) of fractures (fx)
Understand the indications for damage control orthopaedics and stabilization with external fixation (EF) devices
Understand the complications of EF and PP devices
Demonstrate the ability to use the small battery drive
Demonstrate the ability to place K-wires across a fx
Demonstrate the ability to place a simple EF construct

3. 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

4. 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

5. 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

6. K-WIRES AND STEINMANN PINS
Are the same , differentiated by size
K wires – " (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”

7. K-WIRES AND STEINMANN PINS
Trocar or diamond end Smooth or threaded Single or double

8. 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

9. 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

10. 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!!!

11. 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!

12. 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

13. 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!!!!

14. PIN CONFIGURATIONS

15. IDEAL PINNING

16. TYPE III SCH FX Perfect Pinning!
All pins parallel/divergent All pins engage both cortices on both AP and lateral views No cross pins!!

17. 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!

18. 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

19. 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”

20. EXTERNAL FIXATOR Indications
Trauma Open Fractures Severe soft tissue injury Comminution Bone loss Temporizing or Definitive

21. 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

22. DAMAGE CONTROL ORTHOPAEDICS

23. EXTERNAL FIXATOR Advantages
Simplicity and ease of application
Minimal blood loss
Adjustability after surgery
Access for wound management

24. EXTERNAL FIXATOR Disadvantages
Anatomic structures at risk (Safe Zones)
Pin/Wire site infections
Joint contractures
Prolonged time to bony healing

25. EXTERNAL FIXATOR - TIBIA
Simple:
Clamps
Bars
Pins

26. TERMINOLOGY Bars, Rods and Tubes are used interchangeably
bars & rods are solid
tubes are hollow
Pins & Schanz Screws
same

27. EX FIX CLAMPS
Connects pins to rods

28. EX FIX CLAMPS
Combination clamps – connects
Pins to rods
Rods to rods

29. 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

30. 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

31. SAFETY FACTORS
Pin/Wire should not be in the fracture When drilling go slow as not to burn the bone

32. More pins distribute forces and increase construct stiffness
STABILITY FACTORS
Pin/Wire Location
Maximal pin span
More pins distribute forces and increase construct stiffness

33. STABILITY FACTORS
Lower Bone-Rod distance increases stiffness In-line stacking increases stiffness Second sidebar at 90o to first increases stiffness

34. STABILITY FACTORS
Pin/Wire Size Torsional strength proportional to its radius4 Pin core diameter < 1/3 bone diameter

35. 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

36. INSERTING PINS To insert pins: Trocar & 2 sleeves 3.5mm drill bit
Irrigate to prevent heat & pin loosening !
3.5mm inner sleeve for
3.5mm drill bit
5.0mm outer sleeve for
Schanz screw
Trocar

37. INSERTING PINS
Chuck with T handle through outer sleeve Advance to proper depth, just engaging opposite cortex – both a feel and radiographically confirmed

38. ADDING RODS/CLAMPS Use 11mm cannulated socket wrench or ratchet wrench
Need 2 of each for surgeon and assistant
Then reduce fracture
- flouroscopic control

39. PIN CUTTERS AND PROTECTORS
Protects contralateral extremity and allows patient movement

40. Spanning External Fixators
Portable Traction Span intra-articular fracture Aide reduction through ligamentotaxis

41. THE END