External fixator


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This is a lecture presentation on applying external fixator on open fracture specially on tibia. This method is a classical method. Various new and dynamic fixators are there but the basics are the same.

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External fixator

  1. 1. External Fixator
  2. 2. <ul><li>“ External Fixator is a device uses for stabilization and immobilization of long bone open fractures.” </li></ul>
  3. 3. History <ul><li>Earliest recognizable External fixations by Malgaigne 1840 pin for tibial fractures, griffe for patella </li></ul>
  4. 4. <ul><li>Keetley 1893, Ollier, Roux </li></ul>History
  5. 5. <ul><li>Parkhill 1894 Threaded pins and clamp </li></ul>History
  6. 6. <ul><li>Lambotte 1902, self tapping threaded pins, rod, adjustable clamps </li></ul>History
  7. 7. <ul><li>In 1917. Humphry is the 1 st man who uses threaded pins, but he uses only one pin above fracture and one below the fracture site. </li></ul><ul><li>In 1948, Charnley popularized his compression device to facilitate arthrodesis of joints. </li></ul>History
  8. 8. <ul><li>In 1966 and 1974,Anderson et al. uses transfixing pins incorporated into a plaster cast for management of large series of tibial shaft fractures . </li></ul><ul><li>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. </li></ul>History
  9. 9. Today's Fixators
  10. 10. <ul><li>Type -1 Unilateral Uniplanar </li></ul><ul><li>Type -2 Uniplanar Bilateral. </li></ul><ul><li>Type -3 </li></ul><ul><ul><li>Classical Bilateral Biplanar. </li></ul></ul><ul><ul><li>Delta Unilateral Biplanar </li></ul></ul><ul><li>According to Planes: </li></ul><ul><ul><li>Planner: Hoffman’s, orthofix etc. </li></ul></ul><ul><ul><li>Circular: Ilizarov </li></ul></ul>Types
  11. 11. Biomechanics of External Fixator <ul><li>Intrinsic stability of frame (S) </li></ul><ul><li>EX I </li></ul><ul><li>S = ----------- </li></ul><ul><li>L </li></ul><ul><li>E=modulus of elasticity =constant </li></ul><ul><li>I= moment of intertia= constant </li></ul><ul><li>L= distance of frame from axis. </li></ul>
  12. 12. <ul><li>Thus Stiffness is inversely proportional to the distance of the assembly from the bone </li></ul><ul><li>(closer the frame to bone -more stable assembly) </li></ul>Biomechanics
  13. 13. Mechanics of Bone Pin Interface <ul><li>To increase stability of bone –pin interface </li></ul><ul><li>1. Adequate no. of pins in each fragments </li></ul><ul><li>( 2 for most bone & 3 for femur) </li></ul><ul><li>2. Increase pin pitch (3.5mm) </li></ul><ul><li>3. Increase size of pin </li></ul>
  14. 14. <ul><li>A. Schanz screw </li></ul><ul><li>4. 5 short threaded for diaphysis </li></ul><ul><li>5 mm long threaded for metaphysis </li></ul><ul><li>B. Clamps </li></ul><ul><li>1) Universal Clamps </li></ul><ul><li>11) Open ended clamps </li></ul><ul><li>111) Transverse pin adjusting clamps </li></ul><ul><li>1v) Tube to tube clamps. </li></ul><ul><li>C. Tubes 11mm </li></ul>Basic Components
  15. 15. Basic Components
  16. 16. <ul><li>Drill : Hand Drill </li></ul><ul><li>Drill bits – Long drill bits( 200mm) 3.5 and 4.5 mm diameter. </li></ul><ul><li>Triple guide assembly , consist of trocar(3.5mm), inner Sleeve and outer sleeve </li></ul><ul><li>T Handle for insertion of the Schanz screw. </li></ul>Required instruments
  17. 17. Required instruments
  18. 20. <ul><li>External fixation of the tibia is advocated in </li></ul><ul><li>severe open fractures (Gustilo 3b,3c) </li></ul><ul><li>closed fractures with severe soft-tissue injury </li></ul><ul><li>open fractures involving bone loss </li></ul><ul><li>compartment syndrome after fasciotomy </li></ul><ul><li>adjunct to internal fixation </li></ul><ul><li>limb lengthening or bone transport </li></ul>Indications
  19. 21. <ul><li>Soft tissue healed </li></ul><ul><li>If the soft-tissue injuries have healed satisfactorily within 2 weeks without pin track infection, the external fixation can be removed. </li></ul><ul><li>It is then replaced by internal fixation with either a plate or a nail. </li></ul>External fixator as temporary device
  20. 22. <ul><li>Soft-tissue problems persist </li></ul><ul><li>Remove the external fixator </li></ul><ul><li>Temporarily stabilize in cast </li></ul><ul><li>Let pin track infection heal </li></ul><ul><li>If there is pin track infection, using a nail (especially with reaming technique) can lead to intramedullary infection. </li></ul><ul><li>In this case plate osteosynthesis is clearly preferable. </li></ul>External fixator as temporary device
  21. 23. <ul><li>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. </li></ul><ul><li>In children fracture healing is often completed within a period of approximately 6-8 weeks. </li></ul>External fixation as final fixation
  22. 24. External fixation as final fixation
  23. 25. <ul><li>Less damage to blood supply of bone </li></ul><ul><li>Minimal interference with soft-tissue cover </li></ul><ul><li>Useful for stabilizing open fractures </li></ul><ul><li>Rigidity of fixation adjustable without surgery </li></ul><ul><li>Good option in situations with risk of infection </li></ul><ul><li>Requires less experience and surgical skill than standard ORIF </li></ul><ul><li>Quite safe to use in cases of bone infection </li></ul>Advantages
  24. 26. <ul><li>Pin Track Infection. </li></ul><ul><li>Neurovascular Impalement. </li></ul><ul><li>Muscle or Tendon Impalement </li></ul><ul><li>Delayed Union. </li></ul><ul><li>Compartment Syndrome </li></ul><ul><li>Re-fracture </li></ul><ul><li>Limitation of further Alternatives. </li></ul><ul><li>Cosmetic Problem </li></ul>Complications
  25. 27. 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”.
  26. 28. <ul><li>Open fracture Tibia and Fibula </li></ul><ul><li>Open fracture Femur </li></ul><ul><li>Floating Knee </li></ul><ul><li>Open Fracture Humerus </li></ul><ul><li>Communited fracture distal Radius </li></ul><ul><li>Pelvic fracture. </li></ul>Site of insertion
  27. 29. Tibial Safe Zone Proximal part of the proximal tibia
  28. 30. Tibial Safe Zone Proximal 3 rd distal to tibial tuberosity
  29. 31. Tibial Safe Zone Mid Shaft
  30. 32. Tibial Safe Zone Distal 3 rd distal of tibial Shaft
  31. 33. Schanz screw insertion
  32. 34. Schanz screw insertion for Metaphysis
  33. 35. Technique of Applications <ul><li>After adequate skin incision Insert assembled triple sleeve and push onto bone. </li></ul><ul><li>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. </li></ul>
  34. 36. <ul><li>Remove the trocar, insert the long 3.5 drill bit through inner sleeve and drill through both cortices. </li></ul><ul><li>Withdraw the drill bit along with inner sleeve. Insert 4.5 mm drill bit through the outer sleeve and over drill the near cortex. </li></ul>Technique of Applications
  35. 37. <ul><li>Place a 4.5 mm Schanz screw onto the T-handle. Introduce through the outer sleeve and insert into the bone till the thread are securely engaged into the far cortex. </li></ul>Technique of Applications
  36. 38. <ul><li>Insert the triple sleeve through an adequate skin incision and push onto bone. </li></ul><ul><li>Drill the both cortex bone with 3.5 mm drill bit. </li></ul><ul><li>Insert 5mm long threaded Schanz Screw with T-handle. </li></ul>Technique of Applications for metaphysis
  37. 39. <ul><li>Place the most distal Schanz screw using the standard technique. </li></ul><ul><li>Place a universal clamp onto the schanz </li></ul><ul><li>Fix a 11mm tube in this clamp, so that it is posterior to the schanz screw. </li></ul>Application of external fixator
  38. 40. <ul><li>Slide 3 Universal clamps onto this tube. </li></ul><ul><li>Insert most proximal schanz screw. </li></ul><ul><li>Reduction of bone. </li></ul><ul><li>Fix the proximal schanz screw. </li></ul>Application of external fixator…
  39. 41. <ul><li>Insert the 3 rd 4 th schanz screw accordingly. </li></ul><ul><li>Connect frame with another Tube. </li></ul><ul><li>Second tube is clamped in “mirror image” fashion after prestressing. </li></ul>Application of external fixator…
  40. 42. In the OT
  41. 43. In the OT Open fracture Gustilo IIIB with Fixator
  42. 44. In the OT Flap Coverage
  43. 45. <ul><li>Ilizarov External Fixator. </li></ul><ul><li>Universal Mini Fxternal Fixator. </li></ul><ul><li>Modular external Fixator </li></ul>Other External Fixators
  44. 46. Ilizarov External Fixator.
  45. 47. Ilizarov External Fixator.
  46. 48. Ilizarov External Fixator.
  47. 49. Universal Mini External Fixator <ul><li>Micro-motion at fracture Site. </li></ul><ul><li>It is bi-lateral </li></ul><ul><li>More lighter than traditional External Fixator. </li></ul><ul><li>More ligamentotasis </li></ul><ul><li>Less chance of pin tract infections. </li></ul>
  48. 50. UMEX
  49. 51. Modular variety of External Fixator <ul><li>The modular external fixator allows the surgeon to reduce the fracture by manipulation and to hold the reduction. </li></ul><ul><li>Free pin placement allows the surgeon: </li></ul><ul><ul><li>to spread both pins, thereby increasing frame stiffness, </li></ul></ul><ul><ul><li>to position pins according to the fracture pattern or soft-tissue injury, </li></ul></ul><ul><ul><li>to avoid injury to nerves or vessels. </li></ul></ul>
  50. 52. Modular variety of External Fixator
  51. 53. Other variety of External Fixator Synthes Adjustable Tibial exfix Hoffman II external fixation system
  52. 54. Conclusion <ul><li>External Fixator is a good device for the management of open and complicated fractures. </li></ul><ul><li>Surgeon must have knowledge about neurovascular plane of the involved Organ. </li></ul><ul><li>Skill for applying the fixator. </li></ul>
  53. 55. References <ul><li>Course manual: The 3 rd Annual Fracture fixation Course; Eastern India Initiative for Orthopaedic Training </li></ul><ul><li>Uses of External Fixator in orthopaedic surgery; Dr. ABM Golam Farque; a Power Point Presentation. </li></ul><ul><li>Wheeless' Textbook of Orthopaedics http://www.wheelessonline.com/ortho </li></ul><ul><li>Synthes: leading global medical device company. http://us.synthes.com/ </li></ul><ul><li>AO Foundation. <www.aofoundation.com> </li></ul>
  54. 56. Thank You