Note: Descriptions are shown in the official language in which they were submitted.
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PIN PLATE
A fracture near a joint has always been difficult to treat, as the
ideal treatment is to achieve rigid fixation of the fracture fragments
while allowing nearly immediate motion of the joint.
In order to simplify the description the present invention is described
in connection with fractures about the wrist, and particularly those
fractures collectively referred to as Colles' fractures. A person
skilled in the art will appreciate that the invention is also appli-
cable in fixation of other bones. Possible other bones include, but are
not limited to, the distal or lower end of the humerus, the lower tibia
and the lower fibula. This requires a change of the shape of the device
for each specific area, but the same principles are used irrespective
of the site of the fracture. However, the major use of the invention is
thought to be for fixation of Colles' fractures.
Treatment of distal radius fractures has been a problem, both because
of the frequency of the injury as well as the difficulty in treating
them. The goal of treatment is to restore joint congruity and anatomy,
minimize the risk of arthritis, and maximize joint mobility. However,
although these injuries are almost always treated on an outpatient
basis, they typically result in stiffness, arthritis, and diminished
function.
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There are today essentially four general groups of options available
for the treatment of Colles' fractures: (1) closed reduction and cast-
ing, (2) external fixation, (3) open reduction and internal fixation,
and (4) percutaneous pinning and/or limited open pinning. Each method
has its limitations; each has its benefits.
Closed reduction simply involves setting or aligning the broken bone
manually and applying a cast to the arm. This treatment avoids any
trauma associated with surgery, and is cheaper to the medical system.
However, it has several disadvantages. It involves cast immobilization
until healing of the bone fragments occurs; this frequently results in
considerable stiffness. This stiffness is not just confined to the
wrist and forearm. Immobilizing the arm in an elderly individual fre-
quently also results in considerable stiffness to the fingers, elbow,
and shoulder as well. In addition, this technique is very limited in
its ability to hold all but the simplest, most stable fracture patterns
in proper alignment. Unstable fractures commonly redisplace during hea-
ling, which can lead to arthritis and pain.
External fixation involves the application of relatively large diameter
pins inserted into the finger metacarpals and into the radius above the
fracture. These pin clusters are then connected with a bar or frame,
essentially " bypassing " the fracture site. Typically, two pins are
placed in the hand, and two pins in the radius. The frame may distract
the wrist as well, in order to assist with fracture reduction, by using
the soft tissue sleeve around the fracture to help squeeze the frag-
ments into position. Although external fixation has its proponents, it
has its problems. The wrist and hand are rigidly held by the frame, and
the pins through the skin tend to irritate the tendons and cause scar-
ring. These problems together cause considerable stiffness in both the
wrist and the fingers; frequently the functional loss of grip can be
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more disabling than the fracture. Pin site infections may also occur
and compromise results. External fixation may not achieve an anatomic
reduction of the fragments. Currently, external fixation is used for
more severely comminuted, fragmented fractures.
Open reduction involves making an incision over the wrist reducing the
fragments, and applying plates, screws, and pins as needed. For the
Colles' fracture open reduction and internal fixation is seldom used,
for several reasons. First, the trauma associated with the dissection
and exposure can lead to scarring of the tendons, loss of gliding, and
stiffness. Second, the dissection can compromise the blood supply to
the fragments, which can result in delayed unions and occasionally non-
unions. Third, the fragments tend to be small and osteoporotic; drill-
ing holes and placing screws frequently fragments these pieces further,
making anatomic reduction even more difficult. Fourth, most of the
fragments and displacement in the typical Colles' fracture are on the
dorsal side, and the irregularity of the radius in this area together
with. the many tendons found near the bone on this side makes it unde-
sirable to place plates and screws dorsally. Finally, these fractures
are often comprised of numerous small pieces which must be reduced in a
jigsaw puzzle type of arrangement, not easily treated by plate and
screw fixation.
Percutaneous pinning involves the placement: of small stiff pins, also
called K-wires, across fragments of the fracture. The pins may be in-
serted directly through the skin while imaging the fracture with a
fluoroscopy unit. Limited small incisions may also be used. Typically,
pin diameters range from 0.035 " to 0.062 ", with the 0.045 " and
0.054 " pin sizes commonly used in the USA. Pinning has certain
advantages. Using a percutaneous or limited open technique to pin
fragments allows the fracture to be internally fixed. This provides
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some additional stability internally which is not available when the
fracture is treated with a cast alone. The fragments in these fractures
tend to be small and the bone osteoporotic. As a result, pins are more
appropriate as a type of fixation than screws in this setting. A small
diameter pin has less chance of weakening the fragment and comminuting
it further compared with screw holes that are made with even small dia-
meter bone screws.
Pinning, however, has its problems. In order to secure a fragment,
there must be a stable bone nearby for securing the pin. Frequently,
the only stable piece of bone is the proximal fragment, which may be
some distance and at a difficult angle away from the fragment to be
pinned. Since the pins have a small diameter, they are likely to bend
or displace if the stable piece of bone is relatively far from the
fracture fragment. This reduces the ability of the pin to maintain the
position of the fragment and, in turn, impedes the process of healing.
In certain cases multiple fragments are put together like stacking
cards, by fixing one fragment to a stable proximal piece, and then
pinning a second fragment to the first piece, which is assumed to be
stabilized by the first pin. This frequently makes the entire assembly
dependent upon one or two pins which may engage the stable proximal
cortex at some distance from the fracture fragment. Such situations are
often unstable.
Another problem with pinning is that the stable piece of bone that the
fragment is pinned to has to be located on the opposite cortex from
where the pin is inserted. If the only nearby solid piece of bone is
located on the cortex adjacent to the fracture fragment, pinning be-
comes a geometric impossibility. This situation occurs frequently when
a dorsal ulnar fragment occurs. If the opposite volar radial surface is
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fractured in such cases as is often the case, there is no stable cortex
available to the angles of pin insertion that are technically feasible.
Examples of these problems with pinning are often encountered in treat-
s ment of Colles' fractures involving a radial styloid fragment fixed by
a percutaneous trans-styloid pin. The fracture is reduced, and the
fluoroscopy unit is used to pass a pin through the radial styloid on an
angle to engage the ulnar cortex proximal to the distal fragment. The
ability of the pin to hold the radial styloid fracture fragment in an
appropriate position is dependent upon the fixation of the pin in the
stable proximal ulnar cortex. Since the distance to this fixation site
is quite far, and because the small diameter of the pin permits bend-
. ing, small angular deflections of the pin in its site of purchase at
the proximal fragment may lead to significant displacements of the
fractured radial styloid.
Because pins have a strong tendency to bend and displace due to motion
of the joint, pins are hardly ever used without casting. This means
that the patient is still subjected to the common complications of
stiffness and loss of function that is associated with the cast.
Ideally the treatment of distal radius fractures should have the same
goal as treatment of any other fracture near a joint, namely, achiev-
ing rigid fixation of the fracture fragments while allowing nearly im-
mediate mobility of the joint. As can be seen from this discussion,
none of the current methods of treatment achieves this goal. Pins alone
do not provide adequate stability by themselves and still require a
cast. External fixation allows rigid fixation, but does not allow di-
rect reduction of the fracture site, and is associated with consid-
erable morbidity from the complications of stiffness. Closed reduction
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may cause stiffness as well, and frequently fails to
preserve anatomic reduction.
One primary objective of the present invention is to
satisfy the goal of providing rigid fixation of fracture
fragments while allowing immediate motion of a joint. The
means according to the invention provides an implantable
way of constraining by direct contact one or more pins
which have been placed to secure fractured bone fragments.
The present invention will now be described in greater
detail herein-below, with the aid of embodiments shown in
the drawings. In the accompanying drawings:
Fig. 1 is a top view of a radial pin plate according to
one embodiment of the invention;
Fig. 2 is a side view of the pin plate of Fig. 1;
Fig. 3 is an end view of the pin plate of the previous
Figs.;
Fig. 4 is an exploded view of one embodiment of the
invention;
Fig. 5 shows one embodiment of the invention fixed to
the radius;
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Fig. 6 shows one embodiment of the invention fixed in an
alternative location to thE~ radius;
a Fig. 7a-7c are top, side and end views, respectively, of an ulnar
pin plate according to the invention.
As used herein the expression " pin" also covers wire, nail with head
or headless, a thin screw, a threaded pin, pins with bent parts, pins
having a head, pin with nut etc., as well as pins with small beads
either cut or welded at one side. The beads are placed on the side of
the shaft of the pin or at one end of the pin. The difference between
" pins" and "wires" in this case is only the diameters, small diame-
ter ones are called wires and larger diameter ones are called pins.
Thus, to simplify the description the term "pin" is intended to cover
all of the above and similar devices in the description hereinbelow.
Furthermore, the expression " fastening screws" is used for simplicity
in the description of securing the plate to bone, but the fastening
means are not limited to screws. In other embodiments pins, wires,
blades, staples, brackets, or indirect coaption with another device
securely attached to the stable bone fragment through holes in the
plate are used.
In the embodiment of the invention shown in Figs. 1 to 5 the implant
consists of a pin plate 1 having apertures 2, 3 for fastening screws 7
or pins 8, respectively. One or more of the holes 3 for receiving pins
8 is in some embodiments furnished with slots 4 for insertion of the
pins 8 in a way to be described belovr. In some embodiments the holes 3
are chamfered to facilitate the insertion of the pins 8.
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The pin plate 1 is designed to have a form adapted to the intended
place of use. The general form of the radial pin plate 1 is apparent
from Figs. 1 to 3. As is apparent from Figs. 4 and 5 the upper part of
the radial pin plate 1 follows the form of the radial styloid and has a
straight cross-section in end view. The lower part of the pin plate 1
has a semicircular cross-section in end view (Fig. 3) to match the form
of the radius on the dorsal side.
Separate left and right pin plates 1 are furnished as well as pin
plates with varying lengths. In the embodiment of the drawings the pins
8 have a circular cross-section. In other embodiments of the invention
the pins 8 have other cross-sections, such as triangular, quadrangular,
trapezoid etc. Furthermore, in some embodiments the lower part of the
pins 8 have one cross-section, e.g. round, and the upper part another
cross-section, e.g. quadrangular. In order to match pins 8 with
different diameters various plate hole sizes are available. In one
embodiment the pin plate 1 is furnished with holes 3 accepting pins 8
with different diameters. The actual dimensions to be used is decided
by the surgeon in each case based on the specific circumstances such as
fracture site, fragment size, bone condition etc.
Figs. 7a to 7c show one embodiment for an ulnar pin plate 1', i.e. a
pin plate 1' adapted for use on the ulna. The most apparent difference
between the radial pin plate 1 and the ulnar pin plate 1' is the form
of the cross-section in end view. The lower part of the ulnar pin plate
1' has a straight cross-section (Fig. 7c). Apart from the somewhat dif-
ferent form the ulnar pin plate 1' displays the same features as the
radial pin plate 1. Thus, the ulnar pin plate 1' has apertures 2', 3'
and a slot 4' for cooperation with fastening screws and pins, respec-
tively.
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The rigidity of pin fixation of the fracture fragment is considerably
improved by having it pass through one of the small holes 3 and
possibly a tight slot 4 in the pin plate 1 which has been secured to
the proximal fragment 10. After the pin 8 is placed, it can be bent
over the superficial surface of the plate 1 to keep it from migrating.
The pin 8 now has two point fixation, and fragment stability is greatly
enhanced. In addition, the plate can serve an additional role as a
buttress to the distal fragment 9.
The pin plate 1 is securely fixed proximally with one or more screws)
7, pin(s), wire(s), blade(s), staples) brackets) or indirect coapta-
tion with another device to the stable bone fragment through holes in
the plate. The plate has distally holes 3 through which the pin 8 is
passed; additionally, these holes 3 may or may not have slots 4.
If a hole 3 with a slot 4 at the distal portion 5 of the plate 1 is
used, the pin 8 will be placed first, and the plate 1 slid along the
surface of the bone 10 to engage the pin 8. In one embodiment the
entrance slot 4 is slightly undersized, and capable of slight widening
as the pin passes through the slot. This way, the plate 1 will "snap "
as the pin 8 is passed into the slot 4, preventing disengagement. Once
the plate 1 is snapped over the pin 8, the pin 8 is bent to further
secure it, and the plate 1 is fixed proximally with one or two screws 7
or other means of fixation, as indicated above.
Normally the pin, or K-wire, is placed on a high speed drill type appa-
ratus, known as a pin driver, or it may be placed on a standard sterile
operating room drill. In different embodiments the tip of the pin is
either a trochar type, or narrows to a flattened region near the end
which ends in a point. Some designs have a cutting type drill bit on
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the end. Thus, the tip of the pin acts like a drill and allows the tip
to cut through bone as it is inserted.
The fixation of the pins 8 at the pin plate 1 is accomplished in dif-
5 ferent ways in different embodiments of the invention. In one embodi-
ment the pins 8 are bent over the superficial surface of the plate 1 as
stated above. In another embodiment threaded .pins 8 are used which pass
through threaded holes within the plate 1. Optionally, the pins 8 are
locked with locking means such as a locking nut. This provides fixation
10 of the pin 8 in space in both a transverse plane (in the plane of the
plate 1) and an axial plane (along the axis of the pin 8). This varia-
tion further allows a pin 8 to be placed which only purchases the
single adjacent cortex, fixing it in space relative to the position of
the plate 1.
In a further embodiment (not shown) the openings 3 for receiving the
pins 8 are slightly undersized with a cut extending from the hole 3 to
the edge of the plate 1. In this design the pin 8 is captured at the
site of insertion due to the compression of the surrounding undersized
hole. In this situation, a three-pointed clamp is applied to the plate
to place a bending torque on the plate centered at the site of the pin
hole 3; this allows the hole 3 to be enlarged or opened up slightly,
enough so that it allows placement of the pin 8 through the hole 3.
When the clamp is released, the hole 3 returns to its normal outer
diameter, holding the pin 8.
Alternatively, a slotted hole 3 is used which joins a slightly
undersized hole 3, instead of a slightly larger hole. In this cir-
cumstance, as the pin 8 is snapped into the hole 3, it is effectively
locked into place.
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In a further embodiment (not shown) the pin plate 1 is furnished with
one or more threaded studs. The pin 8 is hooked around one stud and
locked against the pin plate 1 with a threaded locking nut on the stud.
3 Instead of locking the pin around the stud, the stud may have a slot
for receiving the pin 8. After the pin has been placed in the slot a
locking nut is screwed onto the stud to lock the pin 8 in the slot of
the stud.
The focus of this device is in securing a traps-styloid radial pin 8.
It makes the fixation of this fragment secure enough so that a cast is
not necessary in most cases. Each plate 1 allows one or more pins 8 in
the distal end. The number of pins 8 used and their angle of insertion
is decided in each case by the surgeon depending on the site and size
of the specific fracture or fractures. In some instances the pin 8 is
inserted through the fragment to engage a stable piece of bone on the
other side of the fragment. In other instances the pin is only inserted
in the adjacent cortex.
In Fig. 5 a pin plate 1 according to the invention is shown in an em-
bodiment for fixation of a traps-styloid pin 8.
In Fig. 6 an alternative pin plate 1 is shown with a design to match
the contour of the bone at the ulnar, dorsal side of the distal radius.
This pin plate 1 is intended for use when there is a need to place a
pin from that side of the distal radius.
The implant of the invention has further applicability in fixation of
other bones besides the radius.
The above detailed description has referred to but a limited number of
embodiments of the present invention, but it will be readily perceived
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by a person skilled in the art that the present invention encompasses a
large number of embodiments without departing from the spirit and scope
of the appended claims.
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