External fixation is used for definitive or temporary treatment of fractures. It has advantages of being minimally invasive and flexible, but disadvantages include potential pin site infections, inadequate immobilization, and soft tissue complications. Key components are pins, clamps, and connecting rods or rings. Pins must be carefully placed to avoid neurovascular injury and ensure stability. Frame construction and pin placement principles maximize stability and load sharing to promote fracture healing. Conversion to internal fixation is generally safe if done within 2-3 weeks to prevent pin track infections from compromising outcomes.
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.
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.
conventional plates including different functions of screws, modes of plate application, Compression Mode.
Neutralization Mode.
Buttress plate.
Antiglide plate.
Bridge plating or span plating.
Tension band.
prebending precountouring
working length
lag screw
AO principles
biological fixation
MIPO
Bone fractures are a very common orthopedic injury resulting from trauma and sudden loads or stresses applied to bones or a result from bones being weakened by certain diseases. More than 250,000 femur fracture patients are seen per year in the U.S. on average. Bone fractures are either a complete or partial break in a bone and in some cases a simple cast to immobilize the injury site is not enough to completely heal the fracture.
Immobilization from casts may not be enough to completely heal the fracture if a malunion (when both ends of the fractured bone misalign) occurs and/or if a non-union (when the fracture gap is too large and the fractured ends cannot re-attach to one another) occurs. In the case of a malunion or non-union, a possible solution to the problem is by surgically inserting an intramedullary rod into the center canal (diaphysial) region of the injured bone and fixating it into place with screws.
conventional plates including different functions of screws, modes of plate application, Compression Mode.
Neutralization Mode.
Buttress plate.
Antiglide plate.
Bridge plating or span plating.
Tension band.
prebending precountouring
working length
lag screw
AO principles
biological fixation
MIPO
Bone fractures are a very common orthopedic injury resulting from trauma and sudden loads or stresses applied to bones or a result from bones being weakened by certain diseases. More than 250,000 femur fracture patients are seen per year in the U.S. on average. Bone fractures are either a complete or partial break in a bone and in some cases a simple cast to immobilize the injury site is not enough to completely heal the fracture.
Immobilization from casts may not be enough to completely heal the fracture if a malunion (when both ends of the fractured bone misalign) occurs and/or if a non-union (when the fracture gap is too large and the fractured ends cannot re-attach to one another) occurs. In the case of a malunion or non-union, a possible solution to the problem is by surgically inserting an intramedullary rod into the center canal (diaphysial) region of the injured bone and fixating it into place with screws.
Slide 35
References
Tornetta P. Rockwood and Green's fractures in adults. Philadelphia: Wolters Kluwer; 2020.
Buckley R, Moran C, Apivatthakakul T. AO principles of fracture management. Davos Platz, Switzerland: AO Foundation; 2017.
Screw and plates are most common used devices in orthopedics. However, sometimes we forget their principles, so this presentation hopes to review most their problems. Thank you for your attention!
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.for more details please visit
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Principles of splints and casts in orthopaedics by Dr. D. P. SwamiDR. D. P. SWAMI
Principles of splints/slabs and casts in orthopaedics. historical perspective, technique of slab/cast application, indications/ contraindications, care of slab/cast
TRAUMATOLOGY OF LOWER LIMB WITH MECHANISM OF INJURY, CLASSIFICATION, RADIOLOGY, NON OPERATIVE/ OPERATIVE TREATMENT, POTENTIAL PROBLEMS AND PREVENTIVE MEASURES
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
3. Indications
• Definitive fx care:
• Open fractures
• Peri-articular fractures
• Pediatric fractures
• Temporary fx care
• “Damage control”
– Long bone fracture
temporization
• Pelvic ring injury
• Periarticular fractures
– Pilon fracture
• Malunion/nonunion
• Arthrodesis
• Osteomyelitis
• Limb deformity/length
inequality
• Congenital
• Acquired
DPS "ONLY FOR EDUCATIONAL
PURPOSES"
4. Advantages
• Minimally invasive
• Flexibility (build to fit)
• Quick application
• Useful both as a temporizing or definitive
stabilization device
• Reconstructive and salvage applications
Complex 3-C humerus fx
DPS "ONLY FOR EDUCATIONAL
PURPOSES"
5. Disadvantages
• Mechanical
– Distraction of fracture site
– Inadequate immobilization
– Pin-bone interface failure
– Weight/bulk
– Refracture (pediatric femur)
• Biologic
– Infection (pin track)
• May preclude conversion to IM nailing or internal fixation
– Neurovascular injury
– Tethering of muscle
– Soft tissue contracture
May result in
malunion/nonunion,
loss of function
DPS "ONLY FOR EDUCATIONAL
PURPOSES"
6. Components of the Ex-fix
• Pins
• Clamps
• Connecting rods
DPS "ONLY FOR EDUCATIONAL
PURPOSES"
7. < 1/3 dia
Pins
• Principle: The pin is the critical link
between the bone and the frame
– Pin diameter
• Bending stiffness
proportional to r4
• 5mm pin 144% stiffer
than 4mm pin
– Pin insertion technique respecting bone and
soft tissue
DPS "ONLY FOR EDUCATIONAL
PURPOSES"
8. Pins
• Various diameters, lengths,
and designs
– 2.5 mm pin
– 4 mm short thread pin
– 5 mm predrilled pin
– 6 mm tapered or conical pin
– 5 mm self-drilling and self tapping
pin
– 5 mm centrally threaded pin
• Materials
– Stainless steel
– Titanium
• More biocompatible
• Less stiff
DPS "ONLY FOR EDUCATIONAL
PURPOSES"
10. Pin coatings
• Recent development of various
coatings (Chlorohexidine, Silver, Hydroxyapatite)
– Improve fixation to bone
– Decrease infection
– Moroni, JOT, ’02
• Animal study, HA pin 13X higher extraction torque vs stainless
and titanium and equal to insertion torque
– Moroni, JBJS A, ’05
• 0/50 pts pin infection in tx of pertrochanteric fx
DPS "ONLY FOR EDUCATIONAL
PURPOSES"
11. Pin Insertion Technique
1. Incise skin
2. Spread soft tissues to
bone
3. Use sharp drill with
sleeve
4. Irrigate while drilling
5. Place appropriate pin
using sleeve
Avoid soft tissue damage and bone
thermal necrosisDPS "ONLY FOR EDUCATIONAL
PURPOSES"
12. Pin insertion
• Self drilling pin
considerations
– Short drill flutes
• thermal necrosis
• stripping of near
cortex with far cortex
contact
– Quick insertion
– Useful for short
term
applications
vs.
DPS "ONLY FOR EDUCATIONAL
PURPOSES"
13. Pin Length
•Half Pins
–single point of entry
–Engage two cortices
•Transfixation Pins
–Bilateral, uniplanar
fixation
–lower stresses at pin
bone interface
–Limited anatomic sites
(nv injury)
–Traveling traction
Courtesy Matthew Camuso
DPS "ONLY FOR EDUCATIONAL
PURPOSES"
14. Pin Diameter Guidelines
•Femur – 5 or 6 mm
•Tibia – 5 or 6 mm
•Humerus – 5 mm
•Forearm – 4 mm
•Hand, Foot – 3 mm
Slide courtesy Matthew Camuso
< 1/3 dia
DPS "ONLY FOR EDUCATIONAL
PURPOSES"
15. Clamps
• Two general varieties:
– Single pin to bar clamps
– Multiple pin to bar clamps
• Features:
– Multi-planar adjustability
– Open vs closed end
• Principles
– Must securely hold the
frame to the pin
– Clamps placed closer to
bone increases the
stiffness of the entire
fixator constructDPS "ONLY FOR EDUCATIONAL
PURPOSES"
17. Bars
•Stainless vs Carbon
Fiber
–Radiolucency
–↑ diameter = ↑
stiffness
–Carbon 15% stiffer vs
stainless steel in loading
to failure
–frames with carbon
fiber are only 85% as stiff
? ? ? ?Weak link is clamp
to carbon bar?
Kowalski M, et al, Comparative Biomechanical Evaluation of Different External Fixator Sidebars: Stainless-Steel Tubes versus
Carbon Fiber Bars, JOT 10(7): 470-475, 1996
Added bar stiffness
≠
increased frame stiffness
DPS "ONLY FOR EDUCATIONAL
PURPOSES"
18. Ring Fixators
• Components:
– Tensioned thin wires
• olive or straight
– Wire and half pin clamps
– Rings
– Rods
– Motors and hinges (not
pictured)
DPS "ONLY FOR EDUCATIONAL
PURPOSES"
19. Ring Fixators
• Principles:
– Multiple tensioned thin wires (90-
130 kg)
– Place wires as close to 90o
to each other
– Half pins also effective
– Use full rings (more difficult to
deform)
• Can maintain purchase in
metaphyseal bone
• Allows dynamic axial loading
• May allow joint motion
DPS "ONLY FOR EDUCATIONAL
PURPOSES"
20. Multiplanar Adjustable Ring Fixators
• Application with wire or half pins
• Adjustable with 6 degrees of freedom
– Deformity correction
• acute
• chronic
DPS "ONLY FOR EDUCATIONAL
PURPOSES"
21. • Type 3A open tibia fracture with bone loss
DPS "ONLY FOR EDUCATIONAL
PURPOSES"
22. • Following frame adjustment and bone
grafting
DPS "ONLY FOR EDUCATIONAL
PURPOSES"
24. Hybrid Fixators
• Combines the
advantages of ring
fixators in periarticular
areas with simplicity
of planar half pin
fixators in diaphyseal
bone
From Rockwood and Green’s, 5th Ed
DPS "ONLY FOR EDUCATIONAL
PURPOSES"
25. Biomechanical Comparison
Hybrid vs Ring Frames
• Ring frames resist axial and bending
deformation better than any hybrid
modification
• Adding 2nd proximal ring and anterior half pin
improves stability of hybrid frame
Pugh et al, JOT, ‘99
Yilmaz et al, Clin Biomech, 2003
Roberts et al, JOT, 2003
Clinical application: Use full ring fixator for fx
with bone defects or expected long frame time
DPS "ONLY FOR EDUCATIONAL
PURPOSES"
26. MRI Compatability
• Issues:
– Safety
• Magnetic field displacing ferromagnetic object
– Potential missile
• Heat generation by induced fields
– Image quality
• Image distortion
DPS "ONLY FOR EDUCATIONAL
PURPOSES"
27. MRI Compatibility
• Stainless steel components (pins, clamps, rings)
most at risk for attraction and heating
• Titanium (pins), aluminum (rods, clamps, rings)
and carbon fiber (rods, rings) demonstrate
minimal heating and attraction
• Almost all are safe if the components are not
directly within the scanner (subject to local policy)
• Consider use of MRI “safe” ex fix when area
interest is spanned by the frame and use
titanium pins
Kumar, JOR, 2006
Davison, JOT, 2004
Cannada, CORR, 1995
DPS "ONLY FOR EDUCATIONAL
PURPOSES"
28. Frame Types
• Standard frame
• Joint spanning frame:
– Nonarticulated
– Articulated frame
• Distraction or Correction frame
DPS "ONLY FOR EDUCATIONAL
PURPOSES"
29. Standard Frame
• Standard Frame
Design
– Diaphyseal region
– Allows adjacent
joint motion
– Stable
DPS "ONLY FOR EDUCATIONAL
PURPOSES"
30. Joint Spanning Frame
• Joint Spanning Frame
– Indications:
• Peri-articular fx
– Definitive fixation through
ligamentotaxis
– Temporizing
» Place pins away from
possible ORIF incision
sites
• Arthrodesis
• Stabilization of limb with
severe ligamentous or
vascular injury: Damage
control
DPS "ONLY FOR EDUCATIONAL
PURPOSES"
31. Articulated Frame
• Articulating Frame
– Limited indications
• Intra- and peri-articular fractures or
ligamentous injury
• Most commonly used in the ankle, elbow and
knee
– Allows joint motion
– Requires precise placement of hinge in the
axis of joint motion
(Figure from: Rockwood and Green, Fractures in Adults, 4th ed, Lippincott-Raven, 1996)
DPS "ONLY FOR EDUCATIONAL
PURPOSES"
32. Correction of Deformity or Defects
• May use unilateral or ring frames
• Simple deformities may use simple frames
• Complex deformities require more complex
frames
• All require careful planning
DPS "ONLY FOR EDUCATIONAL
PURPOSES"
33. • 3B tibia with segmental bone loss, 3A
plateau, temporary spanning ex fixDPS "ONLY FOR EDUCATIONAL
PURPOSES"
34. • Convert to circular
frame, orif plateau
• Corticotomy
and distractionDPS "ONLY FOR EDUCATIONAL
PURPOSES"
38. Fixator Mechanics:
Pin Factors
• Larger pin diameter
• Increased pin spread
– on the same side of the
fracture
• Increased number of
pins (both in and out
of plane of construct)
DPS "ONLY FOR EDUCATIONAL
PURPOSES"
39. Fixator Mechanics:
Pin Factors
• Oblique fxs subject to
shear
• Use oblique pin to
counter these effects
Metcalfe, et al, JBJS B, 2005
Lowenberg, et al, CORR, 2008
DPS "ONLY FOR EDUCATIONAL
PURPOSES"
40. Fixator Mechanics: Rod Factors
• Frames placed in the same plane as the applied load
• Decreased distance from bars to bone
• Stacking of bars
DPS "ONLY FOR EDUCATIONAL
PURPOSES"
41. Frame Mechanics:
Biplanar Construct
• Linkage between
frames in
perpendicular planes
(DELTA)
• Controls each plane of
deformation
DPS "ONLY FOR EDUCATIONAL
PURPOSES"
42. Frame Mechanics: Ring Fixators
• Spread wires to as
close to 90
o
as
anatomically
possible
• Use at least 2 planes
of wires/half pins in
each major bone
segment
DPS "ONLY FOR EDUCATIONAL
PURPOSES"
43. Modes of Fixation
• Compression
– Sufficient bone stock
– Enhances stability
– Intimate contact of bony ends
– Typically used in arthrodesis or to complete union of a fracture
• Neutralization
– Comminution or bone loss present
– Maintains length and alignment
– Resists external deforming forces
• Distraction
– Reduction through ligamentotaxis
– Temporizing device
– Distraction osteogenesis
DPS "ONLY FOR EDUCATIONAL
PURPOSES"
44. Biology
• Fracture healing by stable
yet less rigid systems
– Dynamization
– Micromotion
• micromotion = callus
formation
(Figures from: Rockwood and Green,
Fractures in Adults, 4th ed,
Lippincott-Raven, 1996)
Kenwright, CORR, 1998
Larsson, CORR, 2001 DPS "ONLY FOR EDUCATIONAL
PURPOSES"
45. Biology
• Dynamization = load-
sharing construct that
promote micromotion at
the fracture site
• Controlled load-sharing
helps to "work harden" the
fracture callus and
accelerate remodeling
(Figures from: Rockwood and Green,
Fractures in Adults, 4th ed,
Lippincott-Raven, 1996)
•Kenwright and Richardson, JBJS-B, ‘91
•Quicker union less refracture
•Marsh and Nepola, ’91
•96% union at 24.6 wks
DPS "ONLY FOR EDUCATIONAL
PURPOSES"
46. Anatomic Considerations
• Fundamental knowledge of the anatomy is critical
• Avoidance of major nerves,vessels and organs
(pelvis) is mandatory
• Avoid joints and joint capsules
– Proximal tibial pins should be placed 14 mm distal to articular surface
to avoid capsular reflection
• Minimize muscle/tendon impalement (especially
those with large excursions)
DPS "ONLY FOR EDUCATIONAL
PURPOSES"
48. Upper Extremity “Safe” Sites
• Humerus: narrow lanes
– Proximal: axillary n
– Mid: radial nerve
– Distal: radial, median and ulnar n
– Dissect to bone, Use sleeves
• Ulna: safe subcutaneous border, avoid
overpenetration
• Radius: narrow lanes
– Proximal: avoid because radial n and PIN, thick muscle sleeve
– Mid and distal: use dissection to avoid sup. radial n.
DPS "ONLY FOR EDUCATIONAL
PURPOSES"
49. Damage Control and Temporary Frames
• Initial frame application
rapid
• Enough to stabilize but is
not definitive frame!
• Be aware of definitive
fixation options
– Avoid pins in surgical approach sites
• Depending on clinical
situation may consider
minimal fixation of articular
surface at initial surgery
DPS "ONLY FOR EDUCATIONAL
PURPOSES"
50. Conversion to Internal Fixation
• Generally safe within 2-3 wks
– Bhandari, JOT, 2005
• Meta analysis: 6 femur, 9 tibia, all but one retrospective
• Infection in tibia and femur <4%
• Rods or plates appropriate
• Use with caution with signs of pin irritation
– Consider staged procedure
• Remove and curette sites
• Return following healing for definitive fixation
– Extreme caution with established pin track infection
– Maurer, ’89
• 77% deep infection with h/o pin infection
DPS "ONLY FOR EDUCATIONAL
PURPOSES"
51. Evidence
• Femur fx
– Nowotarski, JBJS-A, ’00
• 59 fx (19 open), 54 pts,
• Convert at 7 days (1-49 days)
• 1 infected nonunion, 1 aseptic
nonunion
– Scalea, J Trauma, ’00
• 43 ex-fix then nailed vs 284
primary IM nail
• ISS 26.8 vs 16.8
• Fluids 11.9l vs 6.2l first 24 hrs
• OR time 35 min EBL 90cc vs
135 min EBL 400cc
• Ex fix group 1 infected
nonunion, 1 aseptic nonunion
Bilat open femur, massive
compartment syndrome, ex fix
then nail
DPS "ONLY FOR EDUCATIONAL
PURPOSES"
52. Evidence
• Pilon fx
– Sirkin et al, JOT, 1999
• 49 fxs, 22 open
• plating @ 12-14 days,
• 5 minor wound problems, 1 osteomyelitis
– Patterson & Cole, JOT, 1999
• 22 fxs
• plating @ 24 d (15-49)
• no wound healing problems
• 1 malunion, 1 nonunion
DPS "ONLY FOR EDUCATIONAL
PURPOSES"
58. Pin-track Infection
• Treatment:
– Stage I: aggressive pin-site care and oral
cephalosporin
– Stage II: same as Stage I and +/- Parenteral Abx
– Stage III: Removal/exchange of pin plus Parenteral
Abx
– Stage IV: same as Stage III, culture pin site for
offending organism, specific IV Abx for 10 to 14
days, surgical debridement of pin site
DPS "ONLY FOR EDUCATIONAL
PURPOSES"
59. Pin Loosening
• Factors influencing Pin
Loosening:
– Pin track infection/osteomyelitis
– Thermonecrosis
– Delayed union or non-union
– Bending Pre-load
DPS "ONLY FOR EDUCATIONAL
PURPOSES"
61. Frame Failure
• Incidence: Rare
• Theoretically can occur with recycling of old
frames
• However, no proof that frames can not be re-
used
DPS "ONLY FOR EDUCATIONAL
PURPOSES"
62. Malunion
Intra-operative causes:
– Due to poor technique
• Prevention:
– Clear pre-operative planning
– Prep contralateral limb for comparison
– Use fluoroscopic and/or intra-operative films
– Adequate construct
• Treatment:
– Early: Correct deformity and adjust or re-apply frame prior to
bony union
– Late: Reconstructive correction of malunion
DPS "ONLY FOR EDUCATIONAL
PURPOSES"
63. Malunion
Post-operative causes:
– Due to frame failure
• Prevention:
– Proper follow-up with both clinical and
radiographic check-ups
– Adherence to appropriate weight-bearing
restrictions
– Check and re-tighten frame at periodic intervals
• Treatment:
– Osteotomy/reconstruction
DPS "ONLY FOR EDUCATIONAL
PURPOSES"
64. Non-union
• Union rates comparable to those achieved with
internal fixation devices
• Minimized by:
– Avoiding distraction at fracture site
– Early bone grafting
– Stable/rigid construct
– Good surgical technique
– Control infections
– Early wt bearing
– Progressive dynamization
DPS "ONLY FOR EDUCATIONAL
PURPOSES"
65. Soft-tissue Impalement
• Tethering of soft tissues can result in:
– Loss of motion
– Scarring
– Vessel injury
• Prevention:
– Check ROM intra-operatively
– Avoid piercing muscle or tendons
– Position joint in NEUTRAL
– Early stretching and ROM exercises
DPS "ONLY FOR EDUCATIONAL
PURPOSES"
66. Compartment Syndrome
• Rare
• Cause:
– Injury related
– pin or wire causing intracompartmental bleeding
• Prevention:
– Clear understanding of the anatomy
– Good technique
– Post-operative vigilance
DPS "ONLY FOR EDUCATIONAL
PURPOSES"
67. Future Areas of Development
• Pin coatings/sleeves
– Reduce infection
– Reduce pin loosening
• Optimization of dynamization for fracture
healing
• Increasing ease of use/reduced cost
DPS "ONLY FOR EDUCATIONAL
PURPOSES"
68. Construct Tips
• Chose optimal pin diameter
• Use good insertion technique
• Place clamps and frames close to skin
• Frame in plane of deforming forces
• Stack frame (2 bars)
• Re-use/Recycle components (requires
certified inspection).
Plan ahead!DPS "ONLY FOR EDUCATIONAL
PURPOSES"
69. References
1. Bhandari M, Zlowodski M, Tornetta P, Schmidt A, Templeman D. Intramedullary Nailing Following External Fixation in Femoral and Tibial Shaft Fractures. Evidence-
Based Orthopaedic Trauma , JOT, 19(2): 40-144, 2005.
2. Cannada LK, Herzenberg JE, Hughes PM, Belkoff S. Safety and Image Artifact of External Fixators and Magnetic Resonance Imaging. CORR, 317, 206-214:1995.
3. Davison BL, Cantu RV, Van Woerkom S. The Magnetic Attraction of Lower Extremity External Fixators in an MRI Suite. JOT, 18 (1): 24-27, 2004.
4. Kenwright J, Richardson JB, Cunningham, et al. Axial movement and tibial fractures. A controlled randomized trial of treatment, JBJS-B, 73 (4): 654-650, 1991.
5. Kenwright J , Gardner T. Mechanical influences on tibial fracture healing. CORR, 355: 179-190,1998.
6. Kowalski, M et al, Comparative Biomechanical Evaluation of Different External Fixator Sidebars: Stainless-Steel Tubes versus Carbon Fiber Bars, JOT 10(7): 470-475,
1996.
7. Kumar R, Lerski RA, Gandy S, Clift BA, Abboud RJ. Safety of orthopedic implants in Magnetic Resonance Imaging: an Experimental Verification. J Orthop Res, 24 (9):
1799-1802, 2006.
8. Larsson S, Kim W, Caja VL, Egger EL, Inoue N, Chao EY. Effect of early axial dynamization on tibial bone healing: a study in dogs. CORR, 388: 240-51, 2001.
9. Lowenberg DW, Nork S, Abruzzo FM. The correlation of shearing force with fracture line migration for progressive fracture obliquities stabilized by external fixation in
the tibial model. CORR, 466:2947–2954, 2008.
10. Marsh JL. Nepola JV, Wuest TK, Osteen D, Cox K, Oppenheim W. Unilateral External Fixation Until Healing with the Dynamic Axial Fixator for Severe Open Tibial
Fractures. Review of Two Consecutive Series , JOT, 5(3): 341-348, 1991.
11. Maurer DJ, Merkow RL, Gustilo RB. Infection after intramedullary nailing of severe open tibial fractures initially treated with external fixation. JBJS-A, 71(6), 835-838,
1989.
12. Metcalfe AJ, Saleh M, Yang L. Techniques for improving stability in oblique fractures treated by circular fixation with particular reference to the sagittal plane. JBJS B,
87 (6): 868-872, 2005.
13. Moroni A, Faldini C, Marchetti S, Manca M, Consoli V, Giannini S. Improvement of the Bone-Pin Interface Strength in Osteoporotic Bone with Use of Hydroxyapatite-
Coated Tapered External-Fixation Pins: A Prospective, Randomized Clinical Study of Wrist Fractures . JBJS –A, 83:717-721, 2001.
14. Moroni A, Faldini C. Pegreffi F. Hoang-Kim A. Vannini F. Giannini S. Dynamic Hip Screw versus External Fixation for Treatment of Osteoporotic Pertrochanteric
Fractures, J BJS-A. 87:753-759, 2005.
15. Moroni A. Faldini C. Rocca M. Stea S. Giannini S. Improvement of the bone-screw interface strength with hydroxyapatite-coated and titanium-coated AO/ASIF cortical
screws. J OT. 16(4): 257-63, 2002 .
16. Nowotarski PJ, Turen CH, Brumback RJ, Scarboro JM, Conversion of External Fixation to Intramedullary Nailing for Fractures of the Shaft of the Femur in Multiply
Injured Patients, JBJS-A, 82:781-788, 2000.
17. Patterson MJ, Cole J. Two-Staged Delayed Open Reduction and Internal Fixation of Severe Pilon Fractures. JOT, 13(2): 85-91, 1999.
18. Pugh K.J, Wolinsky PR, Dawson JM, Stahlman GC. The Biomechanics of Hybrid External Fixation. JOT. 13(1):20-26, 1999.
19. Roberts C, Dodds JC, Perry K, Beck D, Seligson D, Voor M. Hybrid External Fixation of the Proximal Tibia: Strategies to Improve Frame Stability. JOT, 17(6):415-420,
2003.
20. Scalea TM, Boswell SA, Scott JD, Mitchell KA, Kramer ME, Pollak AN. External Fixation as a Bridge to Intramedullary Nailing for Patients with Multiple Injuries and with
Femur Fractures: Damage Control Orthopedics. J Trauma, 48(4):613-623, 2000.
21. Sirkin M, Sanders R, DiPasquale T, Herscovici, A Staged Protocol for Soft Tissue Management in the Treatment of Complex Pilon Fractures. JOT, 13(2): 78-84, 1999.
22. Yilmaz E, Belhan O, Karakurt L, Arslan N, Serin E. Mechanical performance of hybrid Ilizarov external fixator in comparison with Ilizarov circular external fixator. Clin
Biomech, 18 (6): 518, 2003.
DPS "ONLY FOR EDUCATIONAL
PURPOSES"