External FixationIndicationsand Techniques

ObjectivesIdentify the following as they pertain to external fixation:Advantages & disadvantagesIndicationsTypes of framesBiomechanics stabilityPre-operative planningCommon complications

External FixatorA device placed outside the skin that stabilizes bone fragments with pins or wires connected to barsRelative stability Healing with callus

External FixationAdvantagesMinimal damage to blood supply Minimal damage to soft tissuesFixation is away from site of injuryGood option when significant infection risk

External FixationDisadvantages

Restricted joint motionPin tract infectionCumbersome Inadequate stability for certain fractures

IndicationsMost commonly used: TibiaDistal radius

Less commonly used:FemurHumerus Forearm

IndicationsOpen fracturesClosed fractures with soft tissue compromisePeriarticular fracturesPolytrauma/Damage controlPelvic fracturesChildrens fractures

Open FracturesAvoids injury siteAvoids additional injury to soft tissues and vascularity

Open Fractures

Open FracturesSegmental bone loss

Open FracturesFractures needing nerve or vessel repair

Closed Fractures with Soft Tissue Compromise

SwellingFracture blisters

Closed Fractures with Soft Tissue Compromise

Crush injuriesBurns

Closed Fractures with Soft Tissue CompromiseCompartment syndrome

Periarticular FracturesSevere fractures with joint involvement and shaft extension

Periarticular Fractures Spanning ex-fix if axially unstable

Periarticular FracturesHybrid Fixator:Thin wires near jointPins (Schanz Screws) in shaft

Periarticular FracturesReduce and fix the joint surfaceSpan the diaphyseal segment without disturbing soft tissues

Periarticular FracturesExternal fixation can be combined with internal fixation

PolytraumaTemporary stabilization of long bone injuries in unstable patientMinimally invasiveDecreases bleedingPain controlNursing careDamage control

Pelvic FracturesTemporary stabilization for closed fracturesControls hemorrhageDecreases clot shear

Pelvic FracturesOpen pelvic fractures = The lethal injury

Pelvic FracturesQuick applicationOpen or percutaneous pin insertionEasily removed for definitive ORIF

Childrens FracturesFemoral fracturesOne alternative to weeks of skeletal tractionUsed less with use of flexible nails

Childrens FracturesPin placement must avoid growth plateWatch for pin tract infectionOccasional joint stiffness

External FixationFixator construct will depend on treatment strategy: Emergency care Provisional care Definitive care

External Fixator ConstructsUni-planeBi-planeMulti-planeRing

Uni-plane Bi-plane Multi-plane

Uni-plane FixatorSingle Bar

Uni-plane FixatorZ Frame

Uni-plane FixatorDouble Stacked

Bi-plane Fixator

Multi-plane Fixator

Spanning External Fixation

Built as uni- and multi- plane constructsAreas prone to soft tissue problemsKneeAnkleOpen FracturesWhen multiple injuries prevent definitive fixation

Spanning Ex FixAdjunct to Internal FixationTemporaryDefinitive

Increase StabilityPinsLarger diameterMore pins Closer to fracture site

Increase StabilityBars:Closer to limbMore barsSecond plane at right angle to decrease torsion (twisting)

Increase StabilityRings:Smaller is stifferUse smallest diamaeter ring possible but allow for swellingMore rings = more stable

External Fixation AnatomySafe pin placementSafe corridors Know your anatomy to safely place pins!

Intraop SetupCircumferential prep of entire limbRadiolucent tableC-arm

Intraop SetupAssociated proceduresIrrigationDebridementInternal FixationBone graft

Intraop SetupAdequate fixator componentsCannulated screwsLarge/small fragment sets

Intraop TechniqueKeep bars close to bone but. . . allow access for soft tissue careAllow for swellingCan be re-adjusted as needed

Complications Neurovascular injury Pin loosening Pin tract infection Joint stiffness Malalignment Malunion Nonunion

ComplicationsPin tract infections:Most common complicationAvoid fracture areaDont burn bone pre-drillInsert pin completelyRelease skin

ComplicationsKnow where pins are going!

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