Authors of section

Authors

Richard Buckley, Andrew Sands, Michael Castro, Christina Kabbash

Executive Editors

Joseph Schatzker, Richard Buckley

Open all credits

ORIF: screw fixation

1. Principles

Indication

Indication for ORIF is deformity, such as malrotation or malangulation.

Indication for ORIF is deformity, such as malrotation or malangulation.

Stable fixation

Open reduction internal fixation with one or more lag screws may be performed.

hallux proximal phalanx diaphysis simple

Protection plate

When only one lag screw is used, the fixation should be protected with a plate. This enhances the degree of fixation and permits a greater degree of weight bearing which facilitates functional rehabilitation. If possible, insert the lag screw through the plate, as this increases the degree of stability.

orif screw fixation

Percutaneous K-wire fixation

Alternatively, closed reduction using fixation with two or more K-wires may be performed. This may be indicated in patients with poor soft tissue envelope or extensive medical comorbidities.

orif screw fixation

A minimum of two K-wires are required for rotational stability. K-wires may be placed parallel or crossed. For parallel placement, K-wires enter the distal phalanx and exit the first metatarsal proximal to the head.

orif screw fixation

If crossed K-wires are to be inserted, the fracture site should be proximal or distal to where the wires cross.

orif screw fixation

2. Patient preparation and approach

Patient preparation

This procedure is normally performed with the patient in a supine position.

nonoperative treatment

Approach

Diaphyseal fractures of the proximal phalanx of the hallux are best approached through a medial approach (see Medial approach to the hallux).

Diaphyseal fractures of the proximal phalanx of the hallux are best approached through a medial approach.

3. Reduction and preliminary fixation

Direct reduction

Use a periosteal elevator as a lever to reduce the fracture.
Restore anatomical axial rotation, length and angulation.

Use a periosteal elevator as a lever to reduce the fracture.

Placement of the clamp

Apply the points of the reduction clamp so that the points are at right angles to the fracture line. This helps in reducing the fracture and in applying compression.
Once reduced and compressed, maintain the reduction with a K-wire.

Apply the points of the reduction clamp so that the points are at right angles to the fracture line.

Preliminary fixation

The K-wire can be introduced through the same approach, but it must be positioned in such a way that it will not interfere with subsequent fixation.

The K-wire can be introduced through the same approach, but it must be positioned in such a way that it will not interfere with

4. Fixation

Lag screw insertion

These fractures usually have inherent stability, which makes lag screw fixation sufficient. Rarely a plate must be used to protect the lag screw fixation.

orif screw fixation

Preparation and shaping of the plate

Cut the plate to the appropriate length.
Bend and twist the plate to contour it to fit the anatomy of the bone.

orif screw fixation

Application of the plate

Occasionally the middle screw has to be left out if it interferes with the lag screw.

orif screw fixation

5. Aftercare

Immediate postoperative treatment is rest, ice and elevation.

The patient should be encouraged to begin early weight bearing. A stiff-soled, rocker bottom orthosis, such as a cam walker, is helpful in protecting the toe.
Patients must exercise their ankle and subtalar joints out of the cam walker to prevent stiffness.

X-ray the toe at 6 weeks to confirm satisfactory union, and remove K-wires if present. Once the fracture is united, the orthosis may be gradually discarded.
Removal of the lag screw is necessary only if the screw is causing symptoms.

orif plate fixation