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1
“External Fixator is a device uses for
stabilization and immobilization of long
bone open fractures.”

2
History


Earliest recognizable
External fixations by
Malgaigne 1840 pin
for tibial fractures,
griffe for patella

3
History


Keetley 1893, Ollier,
Roux

4
History



Parkhill 1894 Threaded
pins and clamp

5
History



Lambotte 1902, self tapping threaded pins, rod,
adjustable clamps

6
History


In 1917. Humphry is the 1st man who uses threaded pins,
but he uses only one pin above fracture and one below
t...
History




In 1966 and 1974,Anderson et al. uses transfixing pins
incorporated into a plaster cast for management of
la...
9
Types




Type -1 Unilateral Uniplanar
Type -2 Uniplanar Bilateral.
Type -3
◦ Classical Bilateral Biplanar.
◦ Delta Uni...
11
12
For periarticuler fracture
 Thin wire and ring near joint
 Schanz pin in shaft


13

Intrinsic

stability of frame (S)

EX I
S = ----------L

E=modulus of elasticity =constant
I= moment of intertia= const...
Biomechanics


Thus Stability is inversely proportional to the distance of
the assembly from the bone



(closer the fra...
To increase stability of bone –pin interface
1. Adequate no. of pins in each fragments
( 2 for most bone & 3 for femur)
2....
Basic Components
A. Schanz Pin
4. 5mm short threaded for diaphysis
5/6 mm long threaded for metaphysis
B. Clamps
1) Univer...
Basic Components

18
Required instruments


Drill : Hand Drill



Drill bits – Long drill bits( 200mm) 3.5 and 4.5 mm
diameter.



Triple gu...
Required instruments

20


21


22
Indications

severe open fractures (Gustilo 3b,3c)
closed fractures with severe soft-tissue injury or severely
comminuted...
External fixator as temporary device





Soft tissue healed
If the soft-tissue injuries
have healed satisfactorily
wit...
External fixator as temporary device
Soft-tissue problems persist
 Remove the external fixator
 Temporarily stabilize in...
External fixation as final fixation
In the event that soft-tissue
healing is not satisfactory after
4-6 weeks, and there i...
External fixation as final fixation

27
Advantages


Less damage to blood supply of bone



Minimal interference with soft-tissue cover



Useful for stabilizi...
Complications









Pin Track Infection.
Neurovascular Impalement.
Muscle or Tendon Impalement
Delayed Union.
C...
IM nails vs External fixator
Henley (Clin. Orth., 1989) randomised study of
104 case II-IIIB tibial fractures by unreamed ...
Site of insertion







Open fracture Tibia and Fibula
Open fracture Femur
Floating Knee
Open Fracture Humerus
Comm...
Tibial Safe Zone

Proximal part of the proximal tibia
32
Tibial Safe Zone

Proximal 3rd distal to tibial tuberosity
33
Tibial Safe Zone

Mid Shaft
34
Tibial Safe Zone

Distal 3rd distal of tibial Shaft
35
Schanz pin insertion

36
Schanz Pin insertion for Metaphysis

37


After adequate skin incision Insert assembled triple
sleeve and push onto bone.



Hold the sleeve steady and lightly ...
Technique of Applications


Remove the trocar, insert the long 3.5 drill bit through
inner sleeve and drill through both ...
Technique of Applications


Place a 4.5 mm Schanz Pin onto the T-handle.
Introduce through the outer sleeve and insert in...
Technique of Applications for metaphysis


Insert the triple sleeve through an adequate skin
incision and push onto bone....
Application of external fixator


Place the most distal
Schanz Pin using the
standard technique.



Place a universal cl...
Application of external fixator…


Slide 3 Universal clamps
onto this tube.



Insert most proximal
schanz pin.



Redu...
Application of external fixator…


Insert the 3rd 4th schanz
pin accordingly.



Connect frame with
another Tube.



Se...
In the OT

45
In the OT

Open fracture Gustilo IIIB with Fixator
46
In the OT

Flap Coverage
47
Built as uni- and multi- plane constructs
 Areas prone to soft tissue problems


◦ Knee
◦ Ankle
◦ Open Fractures


When...
Spanning ex- fix if axially unstable

49
External fixation can
be combined with
internal fixation

50


Temporary stabilization of long bone injuries in
unstable patient
◦
◦
◦
◦
◦

Minimally invasive
Decreases bleeding
Pain...
Certain intraarticular fracture can be treated by
ex-fix using traction by fixator on the capsule and
ligamentous structur...
Temporary stabilization for closed fractures
 Controls hemorrhage
 Decreases clot shear
 Open pelvic fractures


53
Other External Fixators


Ilizarov External Fixator.



Universal Mini external Fixator.



Modular external Fixator

5...
Ilizarov External Fixator.

55
Ilizarov External Fixator.

56
Ilizarov External Fixator.

57



Micro-motion at fracture Site.
It is bi-lateral



More lighter than traditional External Fixator.



More ligament...
59




The modular external fixator allows the
surgeon to reduce the fracture by
manipulation and to hold the reduction.
Fr...
61
Hoffman II external fixation system
Synthes Tibial exfix Adjustable
62


External Fixator is a good device for the management of
open and complicated fractures.



Surgeon must have knowledge...
Campbell’s

operative orthopedics

Wheeless'

Textbook of Orthopaedics
http://www.wheelessonline.com/ortho
Synthes:

le...
Thank You

65
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External fixator

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External fixator

  1. 1. 1
  2. 2. “External Fixator is a device uses for stabilization and immobilization of long bone open fractures.” 2
  3. 3. History  Earliest recognizable External fixations by Malgaigne 1840 pin for tibial fractures, griffe for patella 3
  4. 4. History  Keetley 1893, Ollier, Roux 4
  5. 5. History  Parkhill 1894 Threaded pins and clamp 5
  6. 6. History  Lambotte 1902, self tapping threaded pins, rod, adjustable clamps 6
  7. 7. History  In 1917. Humphry is the 1st man who uses threaded pins, but he uses only one pin above fracture and one below the fracture site.  In 1948, Charnley popularized his compression device to facilitate arthrodesis of joints. 7
  8. 8. History   In 1966 and 1974,Anderson et al. uses transfixing pins incorporated into a plaster cast for management of large series of tibial shaft fractures . From 1968 to 1970 Vidal and Vidal et al. modified original Hoffmann device from a single half –pin unit to a quadrilateral bicortical frame , greatly increasing rigidity. 8
  9. 9. 9
  10. 10. Types    Type -1 Unilateral Uniplanar Type -2 Uniplanar Bilateral. Type -3 ◦ Classical Bilateral Biplanar. ◦ Delta Unilateral Biplanar  According to Planes: ◦ Planner: Hoffman’s, orthofix etc. ◦ Circular: Ilizarov 10
  11. 11. 11
  12. 12. 12
  13. 13. For periarticuler fracture  Thin wire and ring near joint  Schanz pin in shaft  13
  14. 14.  Intrinsic stability of frame (S) EX I S = ----------L E=modulus of elasticity =constant I= moment of intertia= constant L= distance of frame from axis. 14
  15. 15. Biomechanics  Thus Stability is inversely proportional to the distance of the assembly from the bone  (closer the frame to bone -more stable assembly) 15
  16. 16. To increase stability of bone –pin interface 1. Adequate no. of pins in each fragments ( 2 for most bone & 3 for femur) 2. Increase pin pitch (3.5mm) 3. Increase size of pin 16
  17. 17. Basic Components A. Schanz Pin 4. 5mm short threaded for diaphysis 5/6 mm long threaded for metaphysis B. Clamps 1) Universal Clamps 11) Open ended clamps 111) Transverse pin adjusting clamps 1v) Tube to tube clamps. C. Tubes 11mm 17
  18. 18. Basic Components 18
  19. 19. Required instruments  Drill : Hand Drill  Drill bits – Long drill bits( 200mm) 3.5 and 4.5 mm diameter.  Triple guide assembly , consist of trocar(3.5mm), inner Sleeve and outer sleeve  T Handle for insertion of the Schanz pin. 19
  20. 20. Required instruments 20
  21. 21.  21
  22. 22.  22
  23. 23. Indications severe open fractures (Gustilo 3b,3c) closed fractures with severe soft-tissue injury or severely comminuted fractures or floating knee # open fractures involving bone loss compartment syndrome after fasciotomy adjunct to internal fixation limb lengthening or bone transport fracture associated with severe burn Arthrodesis Infected fractures or nonunions Correction of malunions Fixation after radical tumor excision with autograft or allograft 23
  24. 24. External fixator as temporary device    Soft tissue healed If the soft-tissue injuries have healed satisfactorily within 2 weeks without pin track infection, the external fixation can be removed. It is then replaced by internal fixation with either a plate or a nail. 24
  25. 25. External fixator as temporary device Soft-tissue problems persist  Remove the external fixator  Temporarily stabilize in cast  Let pin track infection heal   If there is pin track infection, using a nail (especially with reaming technique) can lead to intramedullary infection. In this case plate osteosynthesis is clearly preferable. 25
  26. 26. External fixation as final fixation In the event that soft-tissue healing is not satisfactory after 4-6 weeks, and there is no pin track infection, the external fixator can be left on until the fracture has healed. In children fracture healing is often completed within a period of approximately 6-8 weeks. 26
  27. 27. External fixation as final fixation 27
  28. 28. Advantages  Less damage to blood supply of bone  Minimal interference with soft-tissue cover  Useful for stabilizing open fractures  Rigidity of fixation adjustable without surgery  Good option in situations with risk of infection Requires less experience and surgical skill than standard ORIF Quite safe to use in cases of bone infection   28
  29. 29. Complications         Pin Track Infection. Neurovascular Impalement. Muscle or Tendon Impalement Delayed Union. Compartment Syndrome Re-fracture Limitation of further Alternatives. Cosmetic Problem 29
  30. 30. IM nails vs External fixator Henley (Clin. Orth., 1989) randomised study of 104 case II-IIIB tibial fractures by unreamed IM nail; 70 treated by external fixation. Infection rates 7% IM nail, 11% external fixation. There was no difference in time to union. Follow up in 1998 (Journal Orth. Trauma.): “The severity of soft tissue injury rather than the choice of implant appears to be the predominant factor influencing rapidity of bone healing and rate of infection”. 30
  31. 31. Site of insertion       Open fracture Tibia and Fibula Open fracture Femur Floating Knee Open Fracture Humerus Communited fracture distal Radius Pelvic fracture. 31
  32. 32. Tibial Safe Zone Proximal part of the proximal tibia 32
  33. 33. Tibial Safe Zone Proximal 3rd distal to tibial tuberosity 33
  34. 34. Tibial Safe Zone Mid Shaft 34
  35. 35. Tibial Safe Zone Distal 3rd distal of tibial Shaft 35
  36. 36. Schanz pin insertion 36
  37. 37. Schanz Pin insertion for Metaphysis 37
  38. 38.  After adequate skin incision Insert assembled triple sleeve and push onto bone.  Hold the sleeve steady and lightly tap the trocer on to the bone surface in order to create the initial impression. This prevents slipping of the drill bit during drilling. 38
  39. 39. Technique of Applications  Remove the trocar, insert the long 3.5 drill bit through inner sleeve and drill through both cortices.  Withdraw the drill bit along with inner sleeve. Insert 4.5 mm drill bit through the outer sleeve and over drill the near cortex. 39
  40. 40. Technique of Applications  Place a 4.5 mm Schanz Pin onto the T-handle. Introduce through the outer sleeve and insert into the bone till the thread are securely engaged into the far cortex. 40
  41. 41. Technique of Applications for metaphysis  Insert the triple sleeve through an adequate skin incision and push onto bone.  Drill the both cortex bone with 3.5 mm drill bit.  Insert 5mm long threaded Schanz Pin with T-handle. 41
  42. 42. Application of external fixator  Place the most distal Schanz Pin using the standard technique.  Place a universal clamp onto the schanz pin  Fix a 11mm tube in this clamp, so that it is posterior to the schanz pin. 42
  43. 43. Application of external fixator…  Slide 3 Universal clamps onto this tube.  Insert most proximal schanz pin.  Reduction of bone.  Fix the proximal schanz pin. 43
  44. 44. Application of external fixator…  Insert the 3rd 4th schanz pin accordingly.  Connect frame with another Tube.  Second tube is clamped in “mirror image” fashion after prestressing. 44
  45. 45. In the OT 45
  46. 46. In the OT Open fracture Gustilo IIIB with Fixator 46
  47. 47. In the OT Flap Coverage 47
  48. 48. Built as uni- and multi- plane constructs  Areas prone to soft tissue problems  ◦ Knee ◦ Ankle ◦ Open Fractures  When multiple injuries prevent definitive fixation 48
  49. 49. Spanning ex- fix if axially unstable 49
  50. 50. External fixation can be combined with internal fixation 50
  51. 51.  Temporary stabilization of long bone injuries in unstable patient ◦ ◦ ◦ ◦ ◦ Minimally invasive Decreases bleeding Pain control Nursing care “Damage control” 51
  52. 52. Certain intraarticular fracture can be treated by ex-fix using traction by fixator on the capsule and ligamentous structure around the joint.  This work well for comminuted intraarticular fracture of the distal radius.  52
  53. 53. Temporary stabilization for closed fractures  Controls hemorrhage  Decreases clot shear  Open pelvic fractures  53
  54. 54. Other External Fixators  Ilizarov External Fixator.  Universal Mini external Fixator.  Modular external Fixator 54
  55. 55. Ilizarov External Fixator. 55
  56. 56. Ilizarov External Fixator. 56
  57. 57. Ilizarov External Fixator. 57
  58. 58.   Micro-motion at fracture Site. It is bi-lateral  More lighter than traditional External Fixator.  More ligamentotasis  Less chance of pin tract infections. 58
  59. 59. 59
  60. 60.   The modular external fixator allows the surgeon to reduce the fracture by manipulation and to hold the reduction. Free pin placement allows the surgeon: ◦ to spread both pins, thereby increasing frame stiffness, ◦ to position pins according to the fracture pattern or soft-tissue injury, ◦ to avoid injury to nerves or vessels. 60
  61. 61. 61
  62. 62. Hoffman II external fixation system Synthes Tibial exfix Adjustable 62
  63. 63.  External Fixator is a good device for the management of open and complicated fractures.  Surgeon must have knowledge about neurovascular plane of the involved Organ.  Skill for applying the fixator. 63
  64. 64. Campbell’s operative orthopedics Wheeless' Textbook of Orthopaedics http://www.wheelessonline.com/ortho Synthes: leading global medical device company. http://us.synthes.com/ AO Foundation. <www.aofoundation.com> 64
  65. 65. Thank You 65

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