INTRAMEDULLARY PINS IN FIXATION OF FRACTURES OF LONG BONES

The round Steinmann pin alone or in combinations with additional pins, orthopedic wire, Kirschner splint is a very versatile method of skeletal fixation which is applicable to tiny or large breeds and to the very young or mature animals. The objective of rigid skeletal fixation can be achieved if principles of auxiliary skeletal fixation are used in complicated fractures. For uniform success with each of the three types of intramedullary nailing described (Kuentscher, Rush, Steinmann) it is essential that the principles of accurate reduction and rigid fixation be followed. The method of Kuentscher is most limited in application to the dog. Rush pins are somewhat more versatile. The pins can be used singly or in pairs for shaft fractures but have a specific advantage for firm fixation of fractures in the cancellous bone near the ends of the shaft. The Steinmann (round) intramedullary pin is the most versatile, however it is frequently necessary to use auxiliary pins, orthopedic wire, or half Kirschner to achieve rigid fixation.     

Fracture healing after stabilization with intramedullary xenograft cortical bone pins: a study in pigeons

OBJECTIVE: To investigate the effectiveness of intramedullary xenograft cortical bone pins compared with stainless steel Kirschner wire for the repair of a standardized avian humeral fracture. STUDY DESIGN: Prospective randomized study. SAMPLE POPULATION: Thirty mature pigeons (Columba livia). METHODS: Birds were randomly assigned to 3 groups. Transverse mid-diaphyseal humeral fractures were created in 1 humerus in each bird. Fractures were stabilized with intramedullary ostrich or canine xenograft cortical bone pins or Kirschner wire. Radiographic, histological, and biomechanical assessments were used to compare fracture healing 6 weeks after fracture stabilization. The contralateral humerus of each bird was used as a control. RESULTS: All fractures healed regardless of intramedullary pin type. There were no statistically significant biomechanical differences among groups or within groups. Xenograft cortical bone pins induced a mononuclear inflammatory reaction that did not impair bone healing. Bones stabilized with intramedullary cortical bone pins had more periosteal callus and inflammation at the fracture site than bones stabilized with stainless steel Kirschner wires. CONCLUSIONS: Intramedullary xenograft cortical bone pins, derived from mammalian or avian sources, appear to represent an alternative for the repair of avian humeral fractures. CLINICAL RELEVANCE: Intramedullary xenograft cortical bone pins are biodegradable and may reduce the need for additional surgery to remove implants after fracture healing.     

Rotational strength of double-pinning techniques in repair of transverse fractures in femurs of dogs

Transverse midshaft fractures of femurs from freshly euthanatized dogs were stabilized by means of 6 methods: (1) 3.5-mm bone plate and screws, (2) single intramedullary pin, (3) double intramedullary pins retrograded proximally and driven distally to the level of the femoral trochlea, (4) double intramedullary pins retrograded distally and driven proximally into the trochanteric region, (5) double intramedullary pinning in Rush pin fashion, and (6) multiple intramedullary pinning that filled the medullary cavity at the fracture site. All bones were subjected to torsional stress. The measured strain was converted to forces of torque and correlated with bone diameter to normalize the data. The forces of torque from each fixation technique were compared with each other and with the mean torque force necessary to fracture intact femurs. Torsional shear applied to plated femurs resulted in failure at a mean level of 33.8% of the calculated theoretic moment. Torsional forces were concentrated at one end of the plate and catastrophically failed at that point, whereas the fracture site remained rigidly fixed. There was no significant difference in the initial moment of torsional failure between the single intramedullary pin technique (0.05 Nm) and the double-pinning techniques (0.03 to 0.04 Nm). The multiple-pinning technique was 1.8 to 3 times as effective in resisting rotational forces, compared with the other pinning techniques, but not significantly so.     

Radiologic and gross anatomic evaluation of bone healing in the dog.

Bone healing associated with 3 techniques of midshaft femoral fracture fixation in 36 young adult Beagle-type dogs was evaluated in radiographic and gross pathoanatomic studies. A serrated transverse fracture was surgically and aseptically created on the midshaft of either the left or the right femur of each dog. The fixation devices used were intramedullary (IM) pin, IM pin and 1/2 Kirschner device, and tension bone plates. The radiographic evaluation was done in series. The first radiographs were taken during surgery. Radiographs were then taken immediately after surgery, to record the status of reduction, alignment, and fixation. Radiographs were taken at the 4th and 10th postoperative weeks, to monitor healing. All dogs were euthanatized at the 10th week. Both the normal femur and the healing femur were removed from all dogs, all soft tissue was removed from the bone, and each femur was examined grossly. Each type of fixation was associated with a distinct mode of osteogenesis. Bony union and clinical union (that stage in the healing process when fixation can be removed) were defined as a successful conclusion to each case. Malunion and nonunion were defined as unsuccessful conclusions. Delayed union was defined as neither successful nor unsuccessful. The IM pin cases had a 64.2% success rate and a 14.2% failure rate. The IM pin and 1/2 Kirschner cases had a 100% success rate. The bone plate cases were 91% successful, with 0% failure. A problem identified with IM pinning was axial rotation (6 of 14 or 42% of the cases). It was concluded that IM pins should not be used alone for the fixation of femoral fractures in adult dogs.     

Ex Vivo Biomechanical Comparison of Pin Fixation Techniques for Canine Distal Femoral Physeal Fractures

Objective— To compare the biomechanical properties of five intramedullary (IM) pin fixation techniques for Salter-Harris type I fractures of the distal femur in dogs.
Study Design— Randomized, one-way factorial design composed of five treatment groups: (1) single IM pin, (2) dynamic IM crossed pins, (3) paired convergent pins, (4) crossed pins, and (5) crossed polyglycolic acid (PGA) rods.
Sample Population— Forty pairs of cadaver canine femurs.
Materials— One femur of each pair was manually fractured and subsequently repaired; the contralateral intact femur served as its control. Each femur was loaded in torsion until failure occurred and load-deformation curves were generated.
Results— The crossed-pin technique sustained the greatest load to failure (116.8%) followed by the paired convergent pins (104.8%), dynamic IM pins (90.6%), single IM pin (72.1%), and crossed PGA rods (71.9%). Statistically significant differences in strength at failure were detected between the crossed-pin and single IM pin and the crossed-pin and crossed PGA rod techniques. All fixation techniques underwent greater deformation (1.5 times as much) and had a lower stiffness (66% to 75%) compared with the intact controls; however, there was no significant difference between techniques. Failure in the paired convergent and crossed-pin techniques occurred by fracture of the bone; failure in the other techniques occurred by distraction at the fracture site.
Conclusion— The rotational stability of any of the fixation techniques appears to be primarily determined by the ability to prevent distraction and maintain interdigitation of the physis.
Clinical Relevance— When choosing a particular fixation technique for repair of a distal femoral physeal fracture, consideration should be given to the technique's relative biomechanical merits.     

External Skeletal Fixation of Comminuted Maxillary Fractures in Dogs

An external skeletal fixation technique that was effectively applied on comminuted maxillary fractures is described. With this method, pairs of Kirschner wires and/or Steinman pins were seated into the fracture fragments and the exposed cut ends of the pins were embedded into an acrylic bridge. Excellent stabilization of the fractures was effected and normal oral alimentation was resumed immediately. Healing of the fractures usually occurred within two or three months and the pins were then removed. Three representative cases are presented.     

Use of a four pin and methylmethacrylate fixation in L7 and the iliac body to stabilize lumbosacral fracture-luxations: a clinical and anatomic study

Objectives— To describe the clinical outcome of a 4 pin lumbosacral fixation technique for lumbosacral fracture–luxations, and to refine placement technique for iliac pins based on canine cadaver studies.
Study Design— Retrospective and anatomic study.
Sample Population— Dogs (n=5) with lumbosacral fracture-luxations and 8 cadaveric canine pelvi.
Methods— Lumbosacral fracture–luxations were stabilized with a 4 pin (positive-profile threaded) and bone cement fixation. Caudal pins were inserted in the iliac body and cranial pins were inserted into the L7 or L6 pedicle and body. Follow-up examinations and radiographs were performed to assess patient outcome. Intramedullary pins were inserted into the iliac bodies of 8 cadaver pelvi. Radiographs were taken to measure pin insertion angles and define ideal insertion angles that would maximize pin purchase in the ilium.
Results— Follow-up neurologic examination was normal in 4 dogs. Radiographic healing of the fracture was evident in 5 dogs. One implant failure occurred but did not require re-operation. For cadaver iliac pins, mean craniocaudal insertion angle was 29° and mean lateromedial insertion angle was 20°.
Conclusions— Four pin and bone cement fixation effectively stabilizes lumbosacral fracture luxations. The iliac body provides ample bone stock, which can be maximized using an average craniocaudal pin trajectory of 29° and an average lateromedial pin trajectory of 20°.
Clinical Relevance— Lumbosacral fracture–luxations can be stabilized with 4 pin and bone cement fixation in the lumbar vertebrae and iliac body, using 29 and 20° as guidelines for the craniocaudal and lateromedial pin insertion angles in the ilium.     

In vitro biomechanical comparison of three methods for internal fixation of femoral neck fractures in dogs

The in vitro biomechanical properties of three methods for internal fixation of femoral neck fractures were evaluated. Fifty cadaveric femura from Beagle dogs were used. Ten intact femora served as controls. In 40 femura, an osteotomy of the femoral neck was performed to simulate a transverse fracture. With the remaining 30 femura, three repair methods (two medium Orthofix pins, a 2.7 mm cortical bone screw placed in lag fashion and an anti- rotational Kirschner wire, or three divergent 1.1 mm Kirschner wires) were used to stabilize the osteotomies, and 10 osteotomies were stabilised per repair method. These 30 femura where then subject to monotonic loading to failure. Construct stiffness and load to failure were measured. In the remaining 10 femura, pressure sensitive film was placed at the osteotomy site prior to stabilization with either two Orthofix pins (n = 5) or a screw placed in lag fashion (n = 5) to determine the compressive pressure (MPa), compressive force (KN) and area of compression (cm2). There was no significant difference in the stiffness or load to failure for the three repair methods evaluated. There was no significant difference in the compressive pressure, compressive force or area of compression in osteotomies stabilized with Orthofix pins and 2.7 mm bone screws.     

Ex vivo comparison of one versus two distal screws in 8 mm model 11 interlocking nails used to stabilize canine distal femoral fractures

OBJECTIVE: To compare the structural properties of an 8 mm model 11 interlocking nail (IN) with 2 proximal and 2 distal screws (2/2) to 2 proximal and 1 distal screws (2/1) in an unstable canine fracture model. STUDY DESIGN: Ex vivo biomechanical investigation. SAMPLE POPULATION: Eight pairs of adult canine femurs. METHODS: A simple transverse distal metaphyseal femoral fracture with a 1 cm gap was created. The unstable fracture in 1 femur was repaired with a nail with 2 distal and 2 proximal screws and the paired femur with a nail with 1 distal and 2 proximal screws. Cyclic mechanical testing in torsion was performed to assess fatigue life, peak torque, stiffness, and mode of failure. RESULTS: All 2/1 IN-femoral constructs, but only 2 of eight 2/2 constructs, failed before completion of 50,000 loading cycles. The 2/2 constructs had significantly greater peak torque to failure (P = .002) and longer fatigue life (P = .00003) compared with 2/1 constructs. There were no significant differences in stiffness between 2/2 and 2/1 constructs when the non-failed constructs were compared (P > .5). All constructs failed by screw deformation. CONCLUSIONS: An 8 mm model 11 IN used for fixation of unstable canine distal femoral fractures has a longer fatigue life and is stronger under torsional loads when 2 rather than 1 distal screws are placed. CLINICAL RELEVANCE: When repairing unstable canine distal femoral fractures with an IN system, 2 distal screws should be inserted to avoid catastrophic implant failure before bone healing is achieved.     

Multiple Intramedullary Wire Fixation of a Radial Fracture in a Dog

Multiple intramedullary wire fixation infrequently can be used as an alternative technique to plating, transfixation devices, single intramedullary pinning, or external coaptation for some radius and ulna fractures.
This report describes a comminuted fracture of the radius and ulna with fissures and comminution extending too far into the proximal radius for effective application of a bone plate or Kirschner-Ehmer apparatus. Resulting fracture instability and collapse prohibited effective use of external coaptation as a primary means of fixation. The radial fracture was repaired and stabilized with full cerclage wires and multiple intramedullary Kirschner wires. The dog was using the leg normally 12 months following surgery.     

Femoral Capital Physeal Fractures in 25 Foals

The medical records of 25 horses 1 year of age or younger affected with femoral head and neck fractures during an 18 year period were reviewed. Each fracture involved the capital physis. The foals were 11 days to 12 months of age (mean, 5 months). No femoral capital physeal fractures occurred in horses older than 1 year of age during the same period. The history in each case included acute onset of severe unilateral hindlimb lameness, 3 hours to 2 months (mean, 12 days) before presentation. Injuries observed were violent falls, struggles, and kicks. Crepitation, swelling, pain with manipulation or palpation or both, and apparent fracture fragment displacement were inconsistently noted. Tentative clinical diagnoses were confirmed by radiography in 24 foals and by necropsy alone in one foal. Twenty-one foals were euthanatized due to poor prognosis. One foal sent home for stall rest was lost to follow-up. Surgical repair was attempted in three foals. Two fractures were repaired with multiple intramedullary pins and the foals were euthanatized within 2 weeks due to surgical failure and, in one case, contralateral limb breakdown. The third fracture was repaired with a compressing screw and plate device; the animal was pasture sound at month 20.     

Fracture repair with transfixation pins and fiberglass cast in llamas and small ruminants

Transfixation pinning with fiberglass casting is an effective and adaptable method of longbone fracture fixation in llamas and small ruminants. Treatment of fractures in 7 limbs of 4 llamas and 2 small ruminants with this technique are described. Steinmann pins are placed transcortically proximal, and if necessary, distal to the fracture. The pin ends and limb are encased in fiberglass cast material. The cast is strong enough in animals of this size to eliminate the need for external frames or connecting bars. Severely comminuted fractures and fractures near joints are especially suited to fixation with this technique. Complications encountered in these cases included loosening of pins and one delayed union. All fractures healed to permit full use of the limb.     

External fixation of the lumbar spine in a canine model

OBJECTIVE: To compare the mechanical properties of two types of external skeletal fixation of the lumbar spine with polymethylmethacrylate (PMMA)/Steinmann pin fixation in a canine unstable spine model. STUDY DESIGN: Cadaver study. SAMPLE POPULATION: Lumbar spines of 17 mature large-breed dogs. METHODS: Spine stiffness (N-m/deg) in flexion, extension, and rotation under physiological loading conditions and spine strength (N-m) in flexion were determined. Spines were destabilized at L3-L4, instrumented and retested. Fixation techniques included four-pin PMMA (PMMA4), eight-pin PMMA (PMMA8), eight-pin biplanar type I external skeletal fixator (ESF) (SK), and eight-pin spinal arch ESF (ARCHES). RESULTS: All fixation groups were as stiff as intact spines in extension and rotation and were significantly stiffer in flexion. In flexion, both PMMA8 and ARCHES were significantly stiffer than SK, and PMMA8 was significantly stiffer than PMMA4. In rotation, PMMA8 and ARCHES were significantly stiffer than SK, and in flexion to failure, PMMA8 and ARCHES were significantly stiffer than PMMA4. CONCLUSIONS: External skeletal spinal fixation (ESSF) has mechanical properties comparable to more commonly used PMMA/pin internal fixation techniques. CLINICAL RELEVANCE: External fixation of the canine spine has several potential advantages over internal fixation including minimal dissection for pin placement, the ability to span affected vertebrae with placement of implants distant from the site of injury, postoperative adjustability, and complete removal of implants after healing. This study supports the biomechanical stability ESSF of the canine lumbar spine. Further studies are indicated to evaluate zones of consistently safe and secure placement of pins and clinical efficacy.     

Modified transfixation pinning of compound radius and ulna fracture in a heifer

A 405-kg heifer sustained a compound fracture of the distal portion of the radius and ulna after being hit by a car. The fracture was thoroughly debrided, lavaged, and reduced with the heifer under general anesthesia. The fracture was immobilized with a modified walking cast, using 2 fully threaded 6.4-mm (outside diameter) Steinmann pins placed through the proximal portion of the radius. The pins were incorporated into a full-limb fiberglass cast, and a 0.5-cm X 2.25-cm aluminum walking bar was positioned medially and laterally on the limb. The modified walking cast was removed after 7 weeks, and the fracture healed without complication. The transfixation pins and aluminum walking bar helped reduce the strong compressive and rotational forces at the fracture site. The modified walking cast can potentially be used for fixation of a variety of fractures in large animals.     

Intramedullary pinning of femoral diaphyseal fractures in neonatal calves: 12 cases (1980-1990).

Medical records of 12 calves less than or equal to 1 month old, with fracture of the femoral diaphysis, were reviewed. Ten calves were within 1 week of birth at the time of diagnosis. Open reduction was accomplished by use of a lateral approach. Retrograde intramedullary pinning was accomplished in all calves, using 2 (n = 4 calves) or 3 (n = 8 calves) pins. Cerclage wire was used to supplement fixation in 7 calves. A closed continuous suction drain was placed along the lateral aspect of the femur in every calf. Postsurgical complications included seroma formation over the middle gluteal musculature (n = 5 calves), pin migration (n = 6 calves), and osteomyelitis (n = 1 calf). Pin migration was observed in 4 calves that had been treated with nonthreaded trochar point pins. Fractures in 10 of 12 calves (83%) were considered to have healed satisfactorily. One calf was euthanatized because of septic osteomyelitis of the femur. One calf was euthanatized because of persistent lameness and pin migration. Pins were removed in 8 of 12 calves (67%) between the 13th and 90th postoperative days. Results of this study indicate that application of intramedullary pins may be a useful solution for management of femoral diaphyseal fracture in young calves.     

Biomechanical Study of Canine Spinal Fracture Fixation Using Pins or Bone Screws With Polymethylmethacrylate

Five configurations of pins or screws interconnected with polymethylmethacrylate (PMMA) were applied to isolated canine lumbar spines (L2 to L5) in which a complete fracture-luxation had been produced at L3 to L4. Twenty-five repaired spines and five intact control spines were subjected to four-point bending and tested once to failure in ventral flexion. The purpose of this study was to determine the effects of pin number, pin angle, and use of 3.5-mm cortical bone screws instead of smooth 3.2-mm diameter pins on rigidity and ultimate strength of spinal fractures repaired by the implant-PMMA fixation technique. Bending moment versus the angular deformation curves were recorded. Rigidity, bending moment at 10° angular deformation, moment at failure, and deformation at failure of each type of fixation were compared using analysis of variance. Spinal segments stabilized with eight pin-PMMA fixation had significantly greater rigidity and strength at failure than four pin-PMMA fixations ( P < .05). Furthermore, spinal segments stabilized with eight pins angled away from the fracture failed at significantly greater bending moment than those with eight pins angled toward the fracture ( P < .05). However, for four-pin fixation, greater strength was achieved by angling pins in the bone toward the fracture site ( P < .05). Screw-PMMA fixations failed by screw bending and were less rigid and weaker at failure than the corresponding configuration of pin-PMMA fixation ( P < .05).     

Mechanical Evaluation of Half-Pin (Type 1) External Skeletal Fixation in Combination with a Single Intramedullary Pin

Half-pin (type 1) external skeletal fixators with four, three, and two fixation pins and an intramedullary pin, and four-pin external skeletal fixators without an intramedullary pin were applied to prepared canine femurs. Load to failure, load to yield, safe load, and stiffness under compressive and torsional loads were calculated. When tested in compression, all measurements for the four-pin fixators with an intramedullary pin were significantly higher than for the two-pin fixators with an intramedullary pin. The values for all parameters except load to yield were significantly higher for the four-pin fixators with an intramedullary pin than for the four-pin fixators without an intramedullary pin. When tested in torsion, all measurements for the four-pin fixators with an intramedullary pin were significantly higher than for the two or three-pin fixators with an intramedullary pin.     

Surgical repair of rib fractures in 14 neonatal foals: case selection, surgical technique and results

Reasons for performing study: Fractured ribs are encountered quite frequently in newborn Thoroughbred foals, often with fatal outcome. Surgical repair of fractures therefore requires consideration as a means of reducing mortality. Objectives: To evaluate the repair of rib fractures using internal fixation techniques in foals at 2 different equine hospitals following similar diagnostics and case selection. Methods: The records of 14 foals that underwent internal fixation of fracture ribs were reviewed. Subject details, clinical presentation, diagnosis, surgical technique, post operative care and complications were recorded. Follow-up information was obtained in 7 foals. Results: The fractured ribs were reduced and stabilised using reconstruction plate(s), self-tapping cortical screws and cerclage wire in 12 cases, Steinmann pins and cerclage wires in 1 case and both techniques in 1 case. Not every rib was reduced on each case. Surgical reduction was performed on an average of 2 ribs, range 1-3 ribs in each foal. At the time of writing, 4 foals had been sold, one age 2 years was in training and 2 others died from unrelated causes. Conclusions: Our data support the use of surgical stabilisation utilising reconstruction plates, self-tapping cortical screws and cerclage wire for selected cases of thoracic trauma in neonatal foals. The use of Steinmann pins may be suboptimal due to cyclic failure, implant migration and the potential for iatrogenic internal thoracic trauma. Potential relevance: Foals with existing extensive internal thoracic trauma resulting from rib fracture(s), or the potential for such trauma, previously considered to have a guarded to poor prognosis for survival, may be successfully managed with internal fixation of selected fracture sites.     

Relationship of Femoral Intramedullary Pins to the Sciatic Nerve and Gluteal Muscles after Retrograde and Normograde Insertion

An anatomic analysis of retrograde and normograde intramedullary (IM) pinning of proximal, midshaft, and distal femoral fractures was performed in 28 canine cadavers. For all fracture locations, normograde pins were significantly more cranial in the middle gluteal muscle than retrograde pins (p less than 0.01). There was no significant difference between pinning techniques in craniocaudal position of the IM pin in the superficial gluteal muscle. In distal fractures, normograde pins were placed significantly more lateral than retrograde pins in the superficial gluteal muscle (p less than 0.01). One of 15 normograde pins and 9 of 13 retrograde pins were located in the medial half of the trochanteric fossa. Normograde pins were significantly more lateral in the trochanteric fossa than were retrograde pins in midshaft fractures (p less than 0.01). Normograde pins were significantly (p less than 0.01) farther from the sciatic nerve than retrograde pins when the hip was positioned at coxofemoral flexion angles of 85 degrees in midshaft and 110 degrees in distal fractures. Seven of 13 retrograde pins, but none of 15 normograde pins, contacted the sciatic nerve. Normograde pinning of the femur may be less likely to induce sciatic nerve injury, particularly in midshaft and distal fractures.