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CIS
Instrument Continuing Education (ICE)
SELF-STUDY PLANS

Instrument Continuing Education (ICE) lessons provide members with ongoing education in the complex and ever-changing area of surgical instrument care and handling. These lessons are designed for CIS technicians, but can be of value to any CRCST technician who works with surgical instrumentation.

You can use these lessons as an in-service with your staff, or visit www.iahcsmm.org for online grading at a nominal fee ($5 per single lesson plan, or bundled packages are available for quantities of 6 lessons for $25 (save $5) or 12 lessons for $50 (save $10) for greater savings).

Each lesson plan graded online with a passing score of 70% or higher is worth one point (contact hour). You can use these points toward either your re-certification of CRCST (12 points) or CIS (6 points).

Mailed submissions to IAHCSMM will not be graded and will not be granted a point value (paper/pencil grading of the ICE Lesson Plans is not available through IAHCSMM or Purdue University; IAHCSMM accepts only online subscriptions of the ICE Lesson Plans).

Lesson Plan CIS 203
Orthopedic Surgical Instrumentation
[Reprinted from Communiqué: September/October 2007]

Doctors and surgeons who assist people in attaining, maintaining or regaining proper body structure and function are known as Orthopedists. Merriam-Webster defines orthopedic (alternately spelled orthopaedic) as the branch of medicine concerned with the correction or prevention of deformities, disorders, or injuries of the skeleton and associated structures (as tendons and ligaments). Preparing orthopedic surgical instruments requires skill and specialized knowledge. Proper handling in cleaning, inspection and testing of orthopedic instruments helps assure accurate performance of the instruments and positive outcomes for the patient. Certified Instrument Specialist (CIS) provides the basis needed for successful orthopedic surgery, properly functioning, and appropriately packaged sterile instruments. This self-study lesson plan will review classic orthopedic surgical instrumentation.

Skeletal work involves shaping or reshaping of bone, the hardest (most dense) human tissue. Heavy duty, sharp and often large instruments are required to perform these procedures. Delicate instruments are also required, however. The instruments necessary to divide, retract and repair the soft tissues over the bony structure are smaller and lighter in weight. This contrast requires special attention in handling, transport and assembly of orthopedic sets to avoid damage to these instruments. Orthopedic instruments are designed to cut and shape bone, safety is an issue for surgery and sterile processing personnel. Latex gloves are no protection from such sharp edges. Everyone handling these instruments must be mindful to protect themselves and others from injury by following all facility established safety protocols.

Segregation of sharps from soft tissue instruments, replacing all osteotomes, chisels, gouges and curettes into rack/case and utilization of appropriate tip protectors may all be part of a safety protocol. Bone cutting instruments come in a large variety of styles. Each style, meaning shape and function, is often available in a variety of sizes. Simple instruments have no moving parts and include periosteal elevators, chisels, osteotomes, gouges, mallets and curettes. Key periosteal elevators, for example, are available in six graduated sizes. Selection of size is based on the size of the particular bone it will be used upon. A ¼ inch Key elevator would be used on an adult phalanx (finger or toe bone) or a pediatric humerus to lift the fibrous covering (periosteum) from the bone surface. Osteotomes are designed to cut bone, chisels shave and shape bone in one plane or level, and gouges shave bone into a curved surface. These instruments may be curved or straight and are available in a variety of widths. It is important to note that the handle of these instruments should be consistent across the set. Handles may be flat, square, hexagonal, or round. The tip size is graduated and generally only one of each size is included in a set. Packaged sets usually contain all curved or all straight instruments, in sequential order of size, and with like handles.
A mallet is required to use these instruments. Styles vary including head, handle, weight and construction material. Mallet selection will depend on the size of instrument to be struck with the mallet, location of bone and surgeon preference. For instance, a one-pound mallet would not be used with a ¼ inch chisel to reshape nasal bones. Curettes are used to shave and smooth broken or cut bone edges. The tips are bowl-shaped, with a sharp cutting circular edge. Sizes range from microscopic to eight mm. Tips may be straight or angled, depending on the bone surface. Bone is living tissue and should be handled with properly maintained instruments. Jagged cutting surfaces can damage the bone and delay proper healing. The cutting surface should be inspected for dull, nicked or broken edges with a lighted magnifying glass. Follow specific manufacturer instructions regarding sharpness testing and appropriate testing materials.

Ronguers are also called bone biters or bone nibblers. They are available not only in varying sizes, but also in a range of tip styles, bite direction and handle styles. Selection of size and style is, again, related to size of the bone. Is the surgery on a child whose bones are smaller and softer? Is the procedure on a healthy adult whose bones are larger and harder? Is the patient older with fragile bones? Selection of a ‘single action’ style handle will work for the child and older patient, whereas, the healthy adult bones will require a ‘double-action’ style handle. ‘Double action’ allows the instrument to deliver twice as much biting force in the jaws with the same amount of grip pressure needed to operate the ‘single action’ style handle. Another way to describe this action is that a hand grip pressure of 20 pounds will result in 40 pounds of bite pressure. This style ronguer has multiple moving parts which require additional care in cleaning and inspecting. Because these instruments’ jaws remain closed while not in use, force is required to open the jaws for adequate cleaning. There is no mechanism to lock the instrument jaws in an open position. Thorough inspection is needed to ensure that complete cleaning of all surfaces and moving parts has occurred. The direction and angle of bite is another defining point of ronguers. Common (basic) orthopedic sets include Leksell, Stille (a.k.a. duck bill) and Beyer ronguers with bite tips ranging from 3mm to 10 mm. Specialty orthopedic sets include 40° and 90° tip angle Kerrison ronguers in up-biting and down-biting jaws. Again, bone is living tissue and should be handled with properly maintained instruments. Jagged cutting surfaces can damage the bone and delay proper healing. The cutting surface should be inspected for dull, nicked or broken edges with a lighted magnifying glass. Follow specific manufacturer instructions regarding sharpness testing and appropriate testing materials. Additional time is necessary to inspect the multiple moving surfaces for cleanliness and adequate lubrication.

Working on bones also requires special retractors and bone holding forceps. Retractors may be handheld or self-retaining. Most soft tissue retractors are available with dull or sharp tips, such as the rake, Gelpi and Weitlaner retractors. Other retractors are designed to be used to retract and expose specific bones. Bennett femoral retractor, Myers or Blount knee retractor are some examples. Bone hooks are used to distract fractured ends of the bone for realignment. The points must be inspected to ensure they are intact with no burrs to further damage the bone. Bone holding forceps are self-retaining. The majority have sharp prongs to firmly grasp the bone for manipulation without slipping. One exception is the Lowman (a.k.a. turkey claw) bone clamp. All the moving pieces must be inspected for cleanliness, and gripping jaw for intact prongs or surfaces. Remember, bone is living tissue and should be handled with properly maintained instruments. Failure to do so can endanger success of the surgery for the patient.

Bone is strong tissue. The orthopedic surgeon can manipulate, repair or replace portions of bone to improve a patient’s quality of life. Bone must be handled with respect, and that requires quality nstruments that are properly functioning, properly maintained, properly packaged and properly sterilized. This is the realm of the Certified Instrument Specialist. Your efforts are the very basis of successful orthopedic surgery.

References:

International Association of Healthcare Central Service Materiel Management. Central Service Technical Manual. Sixth Edition. 2005.

Instrumentation Resource Course: Identification, Handling and Processing of Surgical Instruments. 2006.

Merriam-Webster Dictionary. Merriam-Webster, Inc. 2005.

K-Medic Orthopedic Sourcebook. 1999.

Storz Surgical Specialities Catalog. 1989.