U.S. patent number 3,561,437 [Application Number 04/714,661] was granted by the patent office on 1971-02-09 for apparatus for fixing fractures of the femur.
Invention is credited to Jose Luis Orlich.
United States Patent |
3,561,437 |
Orlich |
February 9, 1971 |
APPARATUS FOR FIXING FRACTURES OF THE FEMUR
Abstract
Apparatus for fixing fractures of the femur includes a plate
which is held by screws to the upper part of the femur and a
channel like member fixed to the proximal end of the plate for
slidingly engaging a flanged nail which is driven into the head of
the femur. A second embodiment substitutes a cannulated pin which
is inserted into the intramedullary canal of the femur.
Inventors: |
Orlich; Jose Luis (San Jose,
CR) |
Family
ID: |
40328657 |
Appl.
No.: |
04/714,661 |
Filed: |
March 20, 1968 |
Foreign Application Priority Data
Current U.S.
Class: |
606/67 |
Current CPC
Class: |
A61B
17/746 (20130101); A61B 17/744 (20130101) |
Current International
Class: |
A61B
17/68 (20060101); A61B 17/74 (20060101); A61B
17/78 (20060101); A61f 005/04 () |
Field of
Search: |
;128/92.B-B3,C-C,D,F |
References Cited
[Referenced By]
U.S. Patent Documents
Foreign Patent Documents
|
|
|
|
|
|
|
195,043 |
|
1963 |
|
SU |
|
893,401 |
|
Jun 1944 |
|
FR |
|
Other References
Journal of Bone & Joint Surgery p. 7 Jan. 1955 .
Journal of Bone & Joint Surgery p. 38, Oct. 1951 .
Journal of Bone & Joint Surgery p. 162, Feb. 1952.
|
Primary Examiner: Eager; Adele M.
Assistant Examiner: Yasko; J.
Claims
I claim:
1. Apparatus for fixing fractures of the femur comprising a nail to
be driven into the proximal extremity of the femur, an elongated
plate, said plate being curved about its longitudinal axis to
define a concave surface and a convex surface, a plurality of holes
extending through said plate for accepting screws so that said
plate can be secured to the shaft of the femur, a member defining
an elongated open channel having upper and lower boundaries fixed
at one end of said plate, the longitudinal axes of said channel and
said elongated plate defining an obtuse angle, said upper and lower
boundaries of said channel extending outwardly beyond said concave
surface and outwardly beyond said convex surface so that loads
transmitted from said nail to said elongated plate will be
distributed uniformly to said plate by said channel member to
thereby maximize the supporting capability of said apparatus, said
nail being received in said channel for relative sliding movement
therebetween along said nail, and said nail and said channel having
mutually interlocking cross sections to prevent relative rotation
therebetween.
2. Apparatus for fixing a fracture of the femur comprising a nail
to be driven into the upper extremity of the femur, an elongated
pin to be inserted into the intramedullary canal of the femur, a
member defining an open channel fixed at one end of said elongated
pin, the longitudinal axes of said channel and said elongated pin
defining an obtuse angle, said nail being received in said channel
for relative sliding movement therebetween along said nail, an
elongated opening disposed along the longitudinal axis of said
elongated pin, said elongated opening being remote from said
channel, and said nail and said channel having mutual interlocking
cross sections to prevent relative rotation therebetween.
3. Apparatus as defined in claim 2 wherein said opening is an
elongated slot, an elongated fastening member to be inserted in the
femur transversely of said elongated pin and be received in said
elongated slot, and the length of said slot is substantially
greater than the width of said fastening member to permit said
elongated pin to move longitudinally relative to said fastening
member.
Description
This invention relates to apparatus for fixing lesions consisting
primarily of fractures of the femur. More particularly, it relates
to a pin and plate which may be used in combination with a flanged
nail to fix fractures of the upper extremity of the femur which
includes the head, the neck and the trochanters.
Fractures of the femur, particularly fractures of the upper or
proximal end of the femur are rather common. It was early
determined that the setting of such fractures by using casts was
not likely to be very successful. Thereafter, attempts were made at
internal fixation through the use of round or polygonal nails. But
this type of treatment was abandoned because it brought about
partial and temporary fixation only. Then in the late twenties, it
was discovered that good fixation could be achieved by using a
flanged nail. This nail has come to be known as the Smith-Petersen
nail after its inventor.
Soon after the development of the Smith-Petersen nail and its
equivalents, it was determined that even better fixation of the
fracture could be achieved by attaching a plate to the shaft of the
femur. The plate produced particularly good results in the cases of
fractures of the trochanteric region. However, such plates are
rigidly fixed to the end of the nail thereby complicating their
attachment to the femur and making it impossible for the nail to
slide back on the plate to provide impaction at the fracture site.
In addition, such devices do not allow the patient to be mobilized
as soon as he should. This is because the rigid fixation of the
apparatus, which on muscle tension or on weight bearing, applies a
force to the nail which may cause it to move medially and penetrate
the head or neck of the femur, or the reactive force may tear the
plate loose from the shaft of the femur. This condition exists
because the known prior art apparatus does not allow for a
shortening of the apparatus. In the absence of a sliding mechanism,
the patient has to wait until callus is formed. The results of
remaining too long in a sedentary position are well known to those
in the medical profession. It is particularly hazardous for
geriatrics, the group of persons most likely to incur fractures of
the femur, because they readily contract pneumonia, pulmonary
stasis, decubitus ulcers, or generalized weakness.
In accordance with the present invention, the disadvantages of
prior plates and other devices attached to the shaft for use in
combination with a Smith-Petersen nail or its equivalent are
overcome by providing new and unobvious apparatus. In accordance
with the present invention, the apparatus which is fixed to the
shaft of the femur slidingly engages the fixation nail, thereby
permitting impaction at either the fracture or the osteotomy site,
or both. The patient can be immediately mobilized which promotes
impaction and therefore provokes osteogenesis that results in the
formation of callus. In addition, the apparatus permits positioning
of the channel member that retains the nail in a position that
promotes healing.
Some of the advantages of the apparatus for fixing fractures of the
femur described herein can be stated as follows:
The apparatus permits treatment of different types of bone lesion
including fractures, osteoarthritis, and hip fusion;
The apparatus permits immediate weight bearing by the patient;
The apparatus gives a strong immobilization of the parts of the
bone;
The apparatus allows for good alignment of the parts of the
bone;
The apparatus permits impaction of the parts of the bone;
The apparatus promotes faster and better healing;
When used with the operative technique described herein, the
apparatus improves stability by permitting the shifting of the
weight bearing line to a more perpendicular one since the shaft is
displaced medially; and
The apparatus promotes good fixation and healing of even the
unstable transtrochanteric fractures which are a type of fracture
that is poorly held by most of the conventional apparatus.
For the purpose of illustrating the invention, there are shown in
the drawings forms which are presently preferred; it being
understood, however, that this invention is not limited to the
precise arrangements and instrumentalities shown.
FIG. 1 is a perspective view of the first embodiment of this
invention showing a Smith-Petersen nail and plate.
FIG. 2 is a transverse sectional view of the apparatus shown in
FIG. 1 taken along the line 2-2. 4
FIG. 3 is a transverse sectional view of the apparatus shown in
FIG. 1 taken along the line 3-3.
FIG. 4 is a posterior surface view of a femur showing the apparatus
positioned thereon to fix an intracapsular fracture.
FIG. 5 is an elevational view of the second embodiment of the
present invention showing a Smith-Petersen nail positioned on a pin
for insertion into the intramedullary canal.
FIG. 6 is a transverse sectional view of the apparatus shown in
FIG. 5 taken along the line 6-6.
FIG. 7 is a transverse sectional view of the apparatus shown in
FIG. 5 taken along the line 7-7.
FIG. 8 is a view of the posterior surface of the femur showing the
apparatus of FIG. 5 in position to fix a transtrochanteric
fracture.
Referring now to the drawings in detail, wherein like numerals
indicate like elements, there is shown in FIG. 1 the first
embodiment of the apparatus for fixing fractures of the femur
designated generally as 10.
As shown, the apparatus includes a nail 12 of the Smith-Petersen
type. The nail 12 conventionally includes a head 14 which is
adapted to cooperate with an impacting tool which will drive it
into the bone structure of the femur. The nail body 16 supports
three flanges 18, 20 and 22 which extend substantially the entire
length of the nail and are equidistantly spaced apart at angles of
120.degree.. The Smith-Petersen nail is typical of the type of
flanged nail commonly used to fix fractures of the femur. It should
be understood, however, that there are other well-known types of
nails which perform equivalent functions such as diamond shaped
nails similar to the Hansen-Street nail used in surgery for
reducing fractures of the shaft of the femur. Such equivalent nails
may have specialized modifications but are still basically flanged
nails. Accordingly, the Smith-Petersen nail should be regarded as
exemplary rather than limiting.
The nail 12 is supported at the end of the plate 24 by a channel
member 26. Plate 24 is elongated and provided with a plurality of
chamfered holes 28 through which the screws 30 may be inserted for
securing the plate to the shaft of the femur. As shown in FIG. 3,
the plate 24 is curved about its longitudinal axis so as to match
its surface to the curved surface of the lateral aspect of the
femur. It should be noted that the shaft of the human femur is
generally cylindrical and of substantially uniform diameter above
center. Accordingly, little difficulty should be encountered in
fitting the plate 24 to the shaft of any femur.
The plate 24 is bent at its upper or proximal end to provide a
supporting surface 32 for the channel member 26. Channel member 26
which is defined by upper and lower boundaries 33 and 35 is fixed
to the supporting surface by any conventional method of joining
metallic elements.
As best shown in FIGS. 1 and 2, the channel member 26 is a unitary
piece of metal which has been bent or otherwise deformed to define
a channel having an open trefoil cross-sectional shape. The trefoil
or cloverleaf cross-sectional shape has been found to provide
excellent rigidity for the device while simultaneously being
capable of slidingly retaining the nail. The position of the nail
12 in the channel member 26 is best shown in FIG. 2.
The length of the channel member is sufficient to enable it to
slidingly engage the nail 12 so as to prevent any lateral
displacement thereof. As positioned on the supporting surface 32,
the upper and lower boundaries of channel member 26 extend
laterally well beyond the concave surface of the plate 24 and at
least a portion of the boundaries extend laterally outward from the
convex surface of plate 24. Accordingly, the channel member must
necessarily be positioned well below what would normally be the
trochanteric region of the femur and thereby provide good support.
Other types of known plates mount the nail engaging portion well
outside the axis of the shaft thereby reducing their supporting
capability.
The angle between the longitudinal axis of the channel member 26
and the longitudinal axis of the plate 24 can be varied in
accordance with the requirement of the case. In ordinary cases
requiring only the repair of an intracapsular or trochanteric
fracture, the preferable angle is 150.degree. as measured between
the longitudinal axis of the plate 24 and the longitudinal axis of
the channel member 26. This angle is taken in the first and fourth
quadrant of coordinates intersecting at the junction of the
aforesaid longitudinal axes. While 150.degree. is the preferred
angle for fixation of routine fractures, it is anticipated that the
angle between the two longitudinal axes may vary from 115.degree.
to 170.degree. depending upon the type of operation being
performed. For example, in cases of hip arthrodesis, an angle of
170.degree. may be required. In cases of osteoarthritic lesions,
the angle varies depending upon whether the head is found in the
varus or valgus position.
By way of example, but not of limitation, the dimensions of the
plate 24 and channel member 26 can be as follows:
Width of plate 24 - 15 mm.
Thickness of plate 24 - 2.5mm.
Depth of curvature of plate - 4.5mm.
Diameter of holes 28 - 5mm.
Diameter of chamfer for holes 28 - 6.5mm.
Center to center distance between holes 28 - 21mm.
Length of plate 24 - variable (15cm. preferred)
Width of channel member 26 - 15mm.
Thickness of channel member 26 - 2mm.
Depth of channel member - 10mm.
Length of channel member 26 - 25mm.
The nail 12 and plate 24 are shown in position on a femur in FIG.
4. The position shown illustrates how the apparatus 10 may be used
to fix an intracapsular fracture. Briefly summarized, the operative
technique for arriving at this result is as follows:
A. the patient is placed in a prone position on a conventional
operating table with slight flexion of the hip joint at about
15.degree. to 20.degree..
B. the patient is given anesthesia. The type of anesthesia is
determined by the anesthesiologist but an epidural anesthesia is to
be preferred. This type of anesthesia is best for older persons and
the position of the patient on the operating table is suitable for
rendering the same.
C. a posterio-lateral incision is made. This incision is similar to
the type sometimes called the southern approach or Moore incision.
The gluteus maximus and tensor fascia lata are divided along the
line of incision. The vastus lateralis and all external rotator
muscles are separated by blunt bisection from their insertions. The
joint capsule is opened by a midlongitudinal incision so that the
entire proximal end of the femur is exposed.
D. an osteotomy is done at the intertrochanteric region designated
generally by the numeral 40. This allows medial displacement of the
shaft 42 of the femur.
E. the angle of the channel member 26 is chosen according to the
type of fracture or lesion being treated. In the embodiment shown,
the femur is normal in the fracture of the intracapsular type.
Accordingly, a 150.degree. angle is chosen.
F. the plate 24 is screwed to the lateral aspect of the femur shaft
42.
G. a guide hole is drilled through the trochanteric region 40, the
neck 44 and the head 46.
H. thereafter, a nail 12 of the correct type and size is slid into
the channel member 26 and then driven firmly into the head 46. In
certain cases where it is desirable to immobilize the entire joint,
such as cases of arthrodesis, a nail as long as 20 centimeters may
be used. This nail is driven through the head and into the iliac
bone at the acetabulum. It may be driven into the iliac bone as far
up as the sacroiliac joint.
I. the joint capsule is closed and all muscles, facia and skin are
sutured in the conventional manner.
J. finally, impaction of all fragments is done while the patient
remains on the operating table. This is done by striking at the
patient's heel with the leg straight. This impacts the fracture and
immediate weight bearing can be started on the following day.
The advantage of permitting the nail 12 to slide back on the angled
channel 26 is that it allows for impaction at the fracture site or
at the osteotomy site. The entire apparatus, including the plate 24
and nail 12 results in proper alignment of the joints, impaction
and full immobilization of the fracture treated. By using an
osteotomy to position the plate, healing is promoted by
accelerating osteogenesis because more raw bone surface is in
contact at the fracture site. The osteotomy improves stability by
shifting the weight bearing line to one that is more perpendicular
as a result of the shaft 42 being displaced medially.
The entire operative procedure is relatively simple to perform and
the time of performance is relatively short. In most cases, the
plate 24 and pin 12 can be placed in 1 hour. No X-ray control is
required because the hip joint is entirely exposed.
It should be understood the foregoing has been described in respect
to an intracapsular fracture with a brief reference to arthrodesis,
but the apparatus and technique for applying it are equally
applicable to other types of fractures such as transtrochanteric
fracture or an extracapsular fracture with equal facility.
Referring now to FIGS. 5, 6, 7 and 8, there is shown a second
embodiment of the present invention. In this embodiment, the plate
24 is replaced by a pin 50 which supports a nail 12 in a channel
fixed at its proximal end. The nail 12 is of the Smith-Petersen
type and includes a head 14, a body 16 and flanges 18, 20 and 22.
As shown in FIG. 6, the nail 12 is retained in a channel member 52
which is positioned on the proximal end of the pin 50. The pin 50
is cannulated and has an open trefoil cross-sectional shape so as
to define three flanges 54, 56 and 58. The cannulated shape of the
pin 50 permits it to be inserted into the intramedullary canal of
the femur shaft without interferring with the overall function of
that canal. The trefoil shape which defines the three flanges 54,
56 and 58 prevents the pin from rotating once it is inserted in the
intramedullary canal.
An opening in the form of a slot 60 is formed in the central flange
56 of the pin 50 adjacent the junction with the channel member 52.
The longitudinal axis of the slot 60 is parallel to the
longitudinal axis of the pin 50 and in the same plane as the
longitudinal axis of the channel member 52. The slot 60 permits the
insertion of a screw 62 which cooperates with the slot to prevent
rotation of the pin 50. The use of an elongated slot (one that is
substantially longer than the diameter of screw 62) permits the pin
50 to sink into the medullary canal when impaction occurs at the
fracture site. To properly take advantage of this sinking feature,
the screw 62 must extend through the slot 60 adjacent the end which
is remote from the channel member 52.
The channel member 52 is formed as an integral part of the pin 50
and as such flares outwardly and inwardly to define an open trefoil
cross-sectional shape as illustrated in FIG. 6. The channel member
52 receives and retains the nail 12 in the manner shown in FIG. 6
and as described above with respect to the channel member 26. It
should be noted, however, that the channel member 52 extends
laterally only to one side of the pin 50. This is the side opposite
the flange 56. The angle of the longitudinal axis of the channel
member 56 with respect to the longitudinal axis of the pin 50 is
obviously the same as that described with respect to the plate 24
and channel member 26 and measured in the same manner.
By way of example, but not of limitation, the following dimensions
may be used in constructing the pin 50 and its integral channel
member 52:
Length of pin 50 from lower end to junction with channel member 52
- variable, 15cm. being preferred.
Wall thickness of pin 50 - 2mm.
Outside height and outside depth of cross section of pin 50 -
variable between 9 to 14mm.
Length of slot 60 - 25mm.
Width of slot 60 - 4mm.
Length of channel member 52 - 25mm.
Width of channel member 52 - 15mm.
Wall thickness of channel member 52 - 2mm.
Outside depth of channel member 52 - 10mm.
The method of applying the pin 50 and nail 12 is substantially
identical with that described above with respect to the plate 24
and nail 12. The only variation is in step F wherein the proper
size pin is selected according to the size of the intramedullary
canal and placed into such canal. The pin is held in place by the
medullary canal and rotation is prevented by one screw 62 that
extends through the slot 60 adjacent its remote end. Otherwise the
operative technique is identical.
The pin 50 is shown in position within the intramedullary canal of
the shaft 42 of the femur in FIG. 8. In FIG. 8, the pin 50 and nail
12 are used to fix a transtrochanteric fracture of the femur, but
other types of fractures could be fixed. As shown in FIG. 8, the
position of the pin 50 and channel member 52 are well placed to
support the nail 12 and hence promote good fixation of the
fracture.
The operative technique in placing the pin 50 is somewhat faster
than the time required to place the plate 24. Since only one screw
is used, the entire operative technique can normally be completed
in 45 minutes.
From the foregoing, it must be apparent that each of the described
embodiments of this invention accomplish three basic functions
necessary to properly fix a fracture of the femur. The apparatus a
provides good, strong immobilization of the bone parts, b permits
alignment of the bone parts and c allows impaction of the bone
parts. The conjunction of the foregoing three factors produces
better healing.
From the foregoing, it can be seen that there has been described
apparatus for fixing fractures of the femur which accomplishes the
advantages set forth above. Both embodiments can be used to treat
any of the several types of hip lesions such as osteoarthritic
conditions, fractures and arthrodesis of the hip joint. Both
embodiments permit immediate weight bearing after surgery and both
permit almost perfect alignment, impaction and immobilization of
the bone fragments. The natural result of the foregoing is to
provide much shorter healing times.
With respect to intracapsular fractures, both embodiments prevent
nonunion of the femur neck which are frequent when other
conventional devices are used because the fracture is impacted by
muscle tension and primarily because of early weight bearing. Early
weight bearing is achieved because of the sliding nail. The
osteotomy improves the line of weight bearing by medially
displacing the shaft and also promotes osteogenesis.
Transtrochanteric fractures including the unstable ones are
likewise made stable and held in place by good callus formation.
Finally, both devices permit better alignment of the weight bearing
line because the osteotomy permits the shift of the femural shaft
while still holding it in place.
The present invention may be embodied in other specific forms
without departing from the spirit or essential attributes thereof
and, accordingly, reference should be made to the appended claims,
rather than to the foregoing specification as indicating the scope
of the invention.
* * * * *