External FixationExternal FixationIndicationsIndications

and Techniquesand Techniques

ObjectivesObjectives

Identify the following as they pertain to external fixation:– Advantages & disadvantages– Indications– Types of frames– Biomechanics stability– Pre-operative planning– Common complications

External FixatorExternal Fixator

A device placed outside A device placed outside the skin that stabilizes the skin that stabilizes bone fragments with pins bone fragments with pins or wires connected to barsor wires connected to bars

““Relative stability “Relative stability “Healing with callusHealing with callus

External FixationExternal FixationAdvantagesAdvantages

Minimal damage to blood supply Minimal damage to blood supply Minimal damage to soft tissuesMinimal damage to soft tissuesFixation is away from site of injuryFixation is away from site of injuryGood option when significant infection riskGood option when significant infection risk

External FixationExternal FixationDisadvantagesDisadvantages

Restricted joint motionRestricted joint motionPin tract infectionPin tract infectionCumbersome Cumbersome Inadequate stability for certain fracturesInadequate stability for certain fractures

IndicationsIndicationsMost commonly used: Most commonly used:

– TibiaTibia– Distal radiusDistal radius

Less commonly used:Less commonly used:– FemurFemur– Humerus Humerus – Forearm Forearm

IndicationsIndicationsOpen fracturesOpen fracturesClosed fractures with soft tissue Closed fractures with soft tissue

compromisecompromisePeriarticular fracturesPeriarticular fracturesPolytrauma/Damage controlPolytrauma/Damage controlPelvic fracturesPelvic fracturesChildren’s fracturesChildren’s fractures

Open FracturesOpen FracturesAvoids injury siteAvoids injury siteAvoids additional injury Avoids additional injury

to soft tissues and to soft tissues and vascularity vascularity

Open FracturesOpen Fractures

Open FracturesOpen Fractures

Segmental bone lossSegmental bone loss

Open FracturesOpen Fractures

Fractures needing nerve or Fractures needing nerve or vessel repairvessel repair

Closed Fractures with Soft Closed Fractures with Soft Tissue CompromiseTissue Compromise

SwellingSwellingFracture blisters Fracture blisters

Closed Fractures with Soft Closed Fractures with Soft Tissue CompromiseTissue Compromise

Crush injuriesCrush injuriesBurnsBurns

Closed Fractures with Soft Closed Fractures with Soft Tissue CompromiseTissue Compromise

Compartment syndromeCompartment syndrome

Periarticular FracturesPeriarticular Fractures

Severe fractures with joint Severe fractures with joint involvement and shaft involvement and shaft extensionextension

Periarticular FracturesPeriarticular Fractures

• Spanning ex-fix if axially unstableSpanning ex-fix if axially unstable

Periarticular FracturesPeriarticular Fractures

Hybrid Fixator:Hybrid Fixator:– Thin wires near jointThin wires near joint– Pins (Schanz Screws) in shaftPins (Schanz Screws) in shaft

Periarticular FracturesPeriarticular Fractures

Reduce and fix the joint surfaceReduce and fix the joint surfaceSpan the diaphyseal Span the diaphyseal

segment without segment without

disturbing soft tissuesdisturbing soft tissues

Periarticular FracturesPeriarticular Fractures

External fixation can be External fixation can be combined with internal combined with internal fixationfixation

PolytraumaPolytraumaTemporary stabilization of long bone Temporary stabilization of long bone

injuries in unstable patientinjuries in unstable patient– Minimally invasiveMinimally invasive– Decreases bleedingDecreases bleeding– Pain controlPain control– Nursing careNursing care– ““Damage control”Damage control”

Pelvic FracturesPelvic FracturesTemporary stabilization for Temporary stabilization for

closed fracturesclosed fracturesControls hemorrhageControls hemorrhageDecreases clot shearDecreases clot shear

Pelvic FracturesPelvic Fractures

Open pelvic fractures = “The lethal injury”Open pelvic fractures = “The lethal injury”

Pelvic FracturesPelvic Fractures

Quick applicationQuick applicationOpen or percutaneous pin Open or percutaneous pin

insertioninsertionEasily removed for Easily removed for

definitive ORIFdefinitive ORIF

Children’s FracturesChildren’s Fractures

Femoral fracturesFemoral fracturesOne alternative to weeks of One alternative to weeks of

skeletal tractionskeletal tractionUsed less with use of flexible Used less with use of flexible

nailsnails

Children’s FracturesChildren’s Fractures

Pin placement must avoid Pin placement must avoid growth plategrowth plate

Watch for pin tract infectionWatch for pin tract infectionOccasional joint stiffnessOccasional joint stiffness

External FixationExternal Fixation

Fixator construct will depend on treatment Fixator construct will depend on treatment strategy:strategy:– Emergency careEmergency care

– Provisional careProvisional care– Definitive careDefinitive care

External Fixator ConstructsExternal Fixator Constructs

Uni-planeUni-planeBi-planeBi-planeMulti-planeMulti-planeRingRing

• Uni-plane

• Bi-plane

• Multi-plane

Uni-plane FixatorUni-plane FixatorSingle BarSingle Bar

Uni-plane FixatorUni-plane Fixator“Z Frame”“Z Frame”

Uni-plane FixatorUni-plane FixatorDouble StackedDouble Stacked

Bi-plane FixatorBi-plane Fixator

Multi-plane FixatorMulti-plane Fixator

Spanning External FixationSpanning External Fixation

Built as uni- and multi- plane constructs

Areas prone to soft tissue problems– Knee– Ankle– Open Fractures

When multiple injuries prevent definitive fixation

Spanning Ex Fix

Adjunct to Internal FixationAdjunct to Internal Fixation– TemporaryTemporary– DefinitiveDefinitive

Increase StabilityIncrease StabilityPinsPins

– Larger diameterLarger diameter– More pins More pins – Closer to fracture siteCloser to fracture site

Increase StabilityIncrease Stability

Bars:Bars:– Closer to limbCloser to limb– More barsMore bars– Second plane at right Second plane at right

angle to decrease torsion angle to decrease torsion (twisting)(twisting)

Increase StabilityIncrease Stability

Rings:Rings:– Smaller is stifferSmaller is stiffer

Use smallest diamaeter ring Use smallest diamaeter ring possible but allow for swellingpossible but allow for swelling

– More rings = more stableMore rings = more stable

External Fixation AnatomyExternal Fixation Anatomy

Safe pin placementSafe pin placement““Safe corridors” Safe corridors” Know your anatomy to Know your anatomy to

safely place pins!safely place pins!

Intraop SetupIntraop SetupCircumferential prep of entire limbCircumferential prep of entire limbRadiolucent tableRadiolucent tableC-armC-arm

Intraop SetupIntraop Setup

Associated proceduresAssociated procedures IrrigationIrrigationDebridementDebridement Internal FixationInternal FixationBone graftBone graft

Intraop SetupIntraop SetupAdequate fixator componentsAdequate fixator componentsCannulated screwsCannulated screwsLarge/small fragment setsLarge/small fragment sets

Intraop Technique

Keep bars close to bone but…Keep bars close to bone but… . . . allow access for soft tissue . . . allow access for soft tissue

carecare Allow for swellingAllow for swelling Can be re-adjusted as neededCan be re-adjusted as needed

ComplicationsComplications

Neurovascular injuryNeurovascular injury Pin looseningPin loosening Pin tract infectionPin tract infection Joint stiffnessJoint stiffness MalalignmentMalalignment MalunionMalunion NonunionNonunion

ComplicationsComplications

Pin tract infections:Pin tract infections:– Most common complicationMost common complication– Avoid fracture areaAvoid fracture area– Don’t “burn” bone – pre-drillDon’t “burn” bone – pre-drill– Insert pin completelyInsert pin completely– Release skinRelease skin

ComplicationsComplications

Know where pins Know where pins are going!are going!

THANK YOU!THANK YOU!