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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