External fixation involves placing pins or wires connected to bars outside the skin to stabilize bone fragments. It provides relative stability and healing with callus formation. Advantages include minimal damage to soft tissues and blood supply. Disadvantages include restricted motion and pin tract infections. Indications include open fractures, fractures with soft tissue compromise, periarticular fractures, polytrauma, pelvic fractures, and children's fractures. Constructs can be uni-plane, bi-plane, multi-plane, or rings. Stability increases with larger pins, more pins closer to fractures, more bars, and smaller rings. Complications include neurovascular injury, pin loosening, pin tract infections, joint stiffness, malalignment, and malunion/non

1. External FixationExternal Fixation
IndicationsIndications
and Techniquesand Techniques

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

3. External FixatorExternal Fixator
A device placed outsideA device placed outside
the skin that stabilizesthe skin that stabilizes
bone fragments with pinsbone fragments with pins
or wires connected to barsor wires connected to bars
““Relative stability “Relative stability “
Healing with callusHealing with callus

4. External FixationExternal Fixation
AdvantagesAdvantages
Minimal damage to blood supplyMinimal damage to blood supply
Minimal damage to soft tissuesMinimal damage to soft tissues
Fixation is away from site of injuryFixation is away from site of injury
Good option when significant infection riskGood option when significant infection risk

5. External FixationExternal Fixation
DisadvantagesDisadvantages
Restricted joint motionRestricted joint motion
Pin tract infectionPin tract infection
CumbersomeCumbersome
Inadequate stability for certain fracturesInadequate stability for certain fractures

6. IndicationsIndications
Most commonly used:Most commonly used:
– TibiaTibia
– Distal radiusDistal radius
Less commonly used:Less commonly used:
– FemurFemur
– HumerusHumerus
– ForearmForearm

7. IndicationsIndications
Open fracturesOpen fractures
Closed fractures with soft tissueClosed fractures with soft tissue
compromisecompromise
Periarticular fracturesPeriarticular fractures
Polytrauma/Damage controlPolytrauma/Damage control
Pelvic fracturesPelvic fractures
Children’s fracturesChildren’s fractures

8. Open FracturesOpen Fractures
Avoids injury siteAvoids injury site
Avoids additional injuryAvoids additional injury
to soft tissues andto soft tissues and
vascularityvascularity

9. Open FracturesOpen Fractures

10. Open FracturesOpen Fractures
Segmental bone lossSegmental bone loss

11. Open FracturesOpen Fractures
Fractures needing nerve orFractures needing nerve or
vessel repairvessel repair

12. Closed Fractures with SoftClosed Fractures with Soft
Tissue CompromiseTissue Compromise
SwellingSwelling
Fracture blistersFracture blisters

13. Closed Fractures with SoftClosed Fractures with Soft
Tissue CompromiseTissue Compromise
Crush injuriesCrush injuries
BurnsBurns

14. Closed Fractures with SoftClosed Fractures with Soft
Tissue CompromiseTissue Compromise
Compartment syndromeCompartment syndrome

15. Periarticular FracturesPeriarticular Fractures
Severe fractures with jointSevere fractures with joint
involvement and shaftinvolvement and shaft
extensionextension

16. Periarticular FracturesPeriarticular Fractures
• Spanning ex-fix if axially unstableSpanning ex-fix if axially unstable

17. Periarticular FracturesPeriarticular Fractures
Hybrid Fixator:Hybrid Fixator:
– Thin wires near jointThin wires near joint
– Pins (Schanz Screws) in shaftPins (Schanz Screws) in shaft

18. Periarticular FracturesPeriarticular Fractures
Reduce and fix the joint surfaceReduce and fix the joint surface
Span the diaphysealSpan the diaphyseal
segment withoutsegment without
disturbing soft tissuesdisturbing soft tissues

19. Periarticular FracturesPeriarticular Fractures
External fixation can beExternal fixation can be
combined with internalcombined with internal
fixationfixation

20. PolytraumaPolytrauma
Temporary stabilization of long boneTemporary 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”

21. Pelvic FracturesPelvic Fractures
Temporary stabilization forTemporary stabilization for
closed fracturesclosed fractures
Controls hemorrhageControls hemorrhage
Decreases clot shearDecreases clot shear

22. Pelvic FracturesPelvic Fractures
Open pelvic fractures = “The lethal injury”Open pelvic fractures = “The lethal injury”

23. Pelvic FracturesPelvic Fractures
Quick applicationQuick application
Open or percutaneous pinOpen or percutaneous pin
insertioninsertion
Easily removed forEasily removed for
definitive ORIFdefinitive ORIF

24. Children’s FracturesChildren’s Fractures
Femoral fracturesFemoral fractures
One alternative to weeks ofOne alternative to weeks of
skeletal tractionskeletal traction
Used less with use of flexibleUsed less with use of flexible
nailsnails

25. Children’s FracturesChildren’s Fractures
Pin placement must avoidPin placement must avoid
growth plategrowth plate
Watch for pin tract infectionWatch for pin tract infection
Occasional joint stiffnessOccasional joint stiffness

26. External FixationExternal Fixation
Fixator construct will depend on treatmentFixator construct will depend on treatment
strategy:strategy:
– Emergency careEmergency care
– Provisional careProvisional care
– Definitive careDefinitive care

27. External Fixator ConstructsExternal Fixator Constructs
Uni-planeUni-plane
Bi-planeBi-plane
Multi-planeMulti-plane
RingRing

28. • Uni-plane
• Bi-plane
• Multi-plane

29. Uni-plane FixatorUni-plane Fixator
Single BarSingle Bar

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

31. Uni-plane FixatorUni-plane Fixator
Double StackedDouble Stacked

32. Bi-plane FixatorBi-plane Fixator

33. Multi-plane FixatorMulti-plane Fixator

34. 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

35. Spanning Ex Fix
Adjunct to Internal FixationAdjunct to Internal Fixation
– TemporaryTemporary
– DefinitiveDefinitive

36. Increase StabilityIncrease Stability
PinsPins
– Larger diameterLarger diameter
– More pinsMore pins
– Closer to fracture siteCloser to fracture site

37. Increase StabilityIncrease Stability
Bars:Bars:
– Closer to limbCloser to limb
– More barsMore bars
– Second plane at rightSecond plane at right
angle to decrease torsionangle to decrease torsion
(twisting)(twisting)

38. Increase StabilityIncrease Stability
Rings:Rings:
– Smaller is stifferSmaller is stiffer
Use smallest diamaeter ringUse smallest diamaeter ring
possible but allow for swellingpossible but allow for swelling
– More rings = more stableMore rings = more stable

39. External Fixation AnatomyExternal Fixation Anatomy
Safe pin placementSafe pin placement
““Safe corridors”Safe corridors”
Know your anatomy toKnow your anatomy to
safely place pins!safely place pins!

40. Intraop SetupIntraop Setup
Circumferential prep of entire limbCircumferential prep of entire limb
Radiolucent tableRadiolucent table
C-armC-arm

41. Intraop SetupIntraop Setup
Associated proceduresAssociated procedures
IrrigationIrrigation
DebridementDebridement
Internal FixationInternal Fixation
Bone graftBone graft

42. Intraop SetupIntraop Setup
Adequate fixator componentsAdequate fixator components
Cannulated screwsCannulated screws
Large/small fragment setsLarge/small fragment sets

43. 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

44. ComplicationsComplications
 Neurovascular injuryNeurovascular injury
 Pin looseningPin loosening
 Pin tract infectionPin tract infection
 Joint stiffnessJoint stiffness
 MalalignmentMalalignment
 MalunionMalunion
 NonunionNonunion

45. 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

46. ComplicationsComplications
Know where pinsKnow where pins
are going!are going!

47. THANK YOU!THANK YOU!