39

Instruments and Implants

INSTRUMENTS
Periosteum Elevator
Used to elevate the periosteum
Elevation of periosteum is required in all operations on the
bone because all the important structure such as vessels,
nerves, tendons are outside the periosteum
So, once the periosteum is elevated the surgeon is in a safe
plane
All the muscles are attached to the periosteum, so once
periosteum is elevated even the muscles are elevated
Elevation of periosteum is not done in case of excision of
osteochondroma, this prevents recurrence.

Fig. 39.1: Periosteum elevator

Instruments and Implants

Bone Lever
It is used to lever out (lift) a bone from the depth of a wound
after the periosteum is elevated
It is placed between the bone and the periosteum, and thus
retracts the soft tissue

Fig. 39.2: Bone lever

Bone Nibbler
They are used for nibbling of the bone that is to remove a
small piece of bone.

Fig. 39.3: Bone nibbler: angled

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Fig. 39.4: Bone nibbler: straight

Some common bone nibblers are:

1. Curved nibblerFor spinal surgeries
2. Straight nibblerFor general use
3. Double action nibblerThey are superior.
Bone Cutter
It is used for cutting a bone into small pieces
Usually used in bone grafting
It is also available with straight or curved ends and with double
action type

Fig. 39.5: Bone cutter

Instruments and Implants

Osteotome
It is used for cutting of bone (osteotomy)
Both the edges are bevelled
Commonly used in the following osteotomies:
1. Mc Murrays osteotomy for fracture neck femur
2. Corrective osteotomies for Genu varus and Genu valgum

Fig. 39.6: Osteotome

Bone Chisel
It is similar to osteotome except that only one of its surface is
bevelled

Fig. 39.7: Bone chisel

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It is used for:
1. Removing of protruding bone
2. Leveling a bone surface, e.g. for leveling excessive callus,
removing an osteochondroma.
Mallet
Is used for hammering osteotome and chisel.

Fig. 39.8: Mallet

Bone Curette
Uses:
Used for curetting a cavity in the bone
Used for removal of fibrous tissue from the fracture ends of an
old fracture.

Fig. 39.9: Bone curette

Instruments and Implants

Curettage is performed for:
Benign tumors such as enchondroma, giant cell tumor
Infections such as tubercular cavity of bone, osteomyelitis.
Bone Gouge
This is a concave-bladed chisel.
Uses:
Cutting on a round bone
Making round hole in the bone.
Bone awl
This is a pointed instrument; there is an eye at the tip to thread a
wire through the bone
Uses:
Making holes in the bone
Tendon attachment

Fig. 39.10: Bone awl

Bone Holding Forceps

There are three types of forceps used for holding the bone

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They are:
1. Lanes forceps: For holding femur, tibia
2. Lion toothed forceps
3. Self-retaining AO forceps.

Fig. 39.11: Bone holding forceps

Plate Holding Forceps

After the reduction is achieved, a plate of suitable size is placed
over the fracture and held with the help of this instrument.

Fig. 39.12: Plate holding forceps

Instruments and Implants

These are of 2 types:
Lowmans forceps
AO type self-retaining forceps
Gigle Saw
A Gigle saw is a flexible wire saw used for bone cutting.

Fig. 39.13: Gigle saw

Ilizarovs Apparatus
The device is a specialized form of
External fixator, a Circular fixator. Stainless
steel rings are fixed to the bone using K
wires. For more information refer the topic
Ilizarovs technique.
Sequestrum forceps: Used for removal of
sequestrum
Medical Tourniquet
This can be inflated automatically
It is used to control bleeding after
trauma or during surgery

Fig. 39.14: Ilizarovs

apparatus

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Fig. 39.15: Sequestrum forceps

Fig. 39.16: Medical tourniquet

It is usually applied to the proximal portion of the limb

Complication: nerve palsies if applied for too long.
Hand Drill
Used to drill bone manually, other two varieties of bone drill are
electric drill and pneumatic drill.
External fixator
Used in the treatment of compound fractures.
Hexagonal screw drivers
Used to tighten the screw while fixing the plate.

Instruments and Implants

Fig. 39.17: Hand drill

Fig. 39.18: AO external fixator with schantz pins and clamps

Fig. 39.19: Hexagonal screw drivers

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Fig. 39.20: Plaster of Paris (refer chapter treatment

of fracture: general principles)

SS wire
Is used for internal fixation.

Fig. 39.21: SS wire

TRACTION INSTRUMENTS
Kirschner wire
This is a thin straight stainless steel wire.
Uses:
For internal fixation of small bones
For giving traction
To fix fractures in children
Used in Ilizarovs fixation system.

Instruments and Implants

Fig. 39.22: Kirschner wire

Steinmann pin
This is a stout, stainless steel rod, of diameter ranging from
3 to 6 mm
Use: Used for skeletal tractioncommon sites being upper end
of tibia, supracondylar region of femur and calcaneum.
Bohlers Stirrup
Uses
Used for holding a Steinmann pin and applying traction.
The screws on the side of the stirrup are used for holding
the pin.
K-wire stirrup and tensioner
When K wire is used to produce skeletal traction, the strength of
the wire can be increased by subjecting it to an axial tension by
the tensioner.

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Fig. 39.23: Bohlers stirrup with Steinmann pin

Skull traction tongs

For examples, Crutchfield tongs and Blackburn tongs
Uses: In case of cervical injury or diseases.
IMPLANTS
Kuntschers cloverleaf intramedullary nail
Kuntscher, a German surgeon devised the intramedullary nail
for the internal fixation of the femoral fracture
Nail is a hollow tube with a slot on one side
It has a clover shape on cross section
Clover leaf shape gives rotational stability to the fracture
It has eye at its either end onto which hook of the extractor is
introduced while removing the nail.
Determination of the size of K-nail
Length is measured from the tip of greater trochanter to lateral
joint line of knee and then subtract 2 cm from this

Instruments and Implants

Diameter of the K nail is determined by the diameter of the
marrow at the level of isthmus.
Introduction of the nail can be done in two ways
Retrograde: Introduction is from the fracture site hammered
out proximal so that it comes out of greater trochanter
fracture is reduced nail is driven into distal fragment
Nail is introduced through the greater trochanter guided
through a guided wire to fracture site and as K nail comes out
through the fracture site, guide wire is removed and fracture is
reduced under supervision and the nail is driven home
About 2 cm of the nail is left protruding at the trochanter to
facilitate its removal after 2 years, an extractor is introduced
into the eye of the K nail and then removed.
Complications of K nailing
Nail gets stuck
Splintering of cortex while hammering the nail
Proximal migration of the nail, causing bursitis in the protruding
part
Distal migration of the nail causing stiffness of the knee
Infection

Fig. 39.24: K nail

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Smith-Petersen nail (SP nail)
SP nail is a cannulated triflanged nail
It is an implant used for internal fixation of fracture neck of
femur
The advantages of the triflanged nail are:
It prevents axial rotation of the fragments
It cuts only a little bone to provide good stability
It can be used along with McLaughlins plate for the fixation
of intertrochanteric fracture.

Fig. 39.25: SP nail

Dynamic hip screws (DHS)

It has two components The lag screw and the barrel
The lag screw slides freely inside the barrel, so that if there is
a collapse at the fracture site, the screw does not cut out of
the cortex, it telescopes into the barrel
Uses: Used for the internal fixation of the trochanteric fracture

Fig. 39.26: DHS

Instruments and Implants

PLATES AND SCREWS
These are used to fix 2 bony fragments
Different types of the plates are:
1. Heavy duty broad
2. Narrow plates
Screws may be used alone or in combination with the plate
In the past machine screws (self-tapping) screws were used,
but now nontapping screws are used (AO screws)
Nontapping screws are better than self-tapping screws,
because in the self-tapping screw, while tightening, heat is
produced at the bone screw interface causing necrosis of
born and thus loosening of the screws
For a nontapping screw, threads are cut in the bone with a
special instrument called bone tap.

Fig. 39.27: Reconstruction plate, DCP narrow 3.5 mm, DCP heavy duty
4.5 mm, DCP broad,
DCP =dynamic compression plate

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Fig. 39.28: (Left to Right) Lock compression plate for upper humerus,
one-third tubular plate, T plate for distal radius, Ellis plate

Fig. 39.29: Interference screw, locking bolt for nail, cortical screw,
cancellous screw, malleolar screw, canulated cancellous screw

Instruments and Implants

PROSTHESIS
Austin-Moore prosthesis
Used for the replacement of femoral
head in case of fracture neck of the
femur in elderly person
It is available in odd number sizes
from 35 to 59 mm
There is a small hole in the top of the
stem for the hook of the extractor
used while removing the prosthesis
The stem has two fenestrations in
the middle, through which bone
supposedly grows and helps in
fixation of the prosthesis
This prosthesis can thus be used
only without cement because the use
of cement would make its removal if
required, difficult.
Thompson prosthesis
This is prosthesis for the head of
the femur, similar to Austin-Moore
prosthesis
It is especially indicated in cases
where the neck of the femur is
absorbed, e.g. in old fractures of the
femoral neck
It can be used with or without
cement.

Fig. 39.30: AustinMoore prosthesis

Fig. 39.31: Thompson

prosthesis

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Charnleys total hip prosthesis
This is prosthesis for the replacement of both the acetabulum
and the head of the femur
The acetabulum is replaced by a plastic acetabulum cup and
the head by a steel component
Both the components are fitted to
their respective components by
using bone cement
The size of the head of the
prosthesis is 22 mm.
Mullers total hip prosthesis
It is similar to Charnleys prosthesis,
except for the size of the head of
this prosthesis which is 32 mm
Stem is available in different
thickness.
Fig. 39.32: Charnleys total
Total knee prosthesis
hip prosthesis
Total condylar design is the most
popular one of the different
designs available
In this type, the articular surfaces
of the femur (metallic), patella and
tibia (plastic) are replaced
Common prosthesis used are InsallBurstein knee and FreemanSamuelson knee.
Fig. 39.33: Total knee
prosthesis