Principles of External

Fixation
-Dr. Abhishek Garg
MS Orthopaedic
 Introduction
 History
 advantage vs disadvantage
 Indications
 Types
 Construct design
 Parts
 Factors affecting stiffness
 Surgical techniques
 complications
 External fixation is a device placed outside the skin which stablizes
the bone fragment through wires or pins connected to one or more
longitudinal bar/tube
Historical perspective
 Advantage Disadvantage

• Less damage to blood supply of the bone • Pin and wire penetrating the soft tissues
• Minimal interference with soft tissue cover • Restricted joint motion
• Rapid application in an emergency situation • Pin tract complication in long lasting external
• Stabilization of open an contaminated fracture fixation
• Cumbersome and not always well tolerated
• Adjustment of fracture reduction and stability
without surgery • Limited stiffness in certain location
• Minimal foreign body in the presence of
infection
• Less experience and surgical skill required than
for standard open reduction and internal
fixation
• Bone transport and deformity correction
possible
Indication for external fixation

 Open fracture
External fixation is one option for the temporary or definitive skeletal stabilization of open fractures, in particular
those with severe soft-tissue injury
External fixation can be applied with minimal trauma, avoiding additional damage to soft tissues and bone
vascularity

 Closed fractures
In closed fractures, external fixation is indicated for temporary bridging in severe polytrauma and severe closed
soft-tissue contusions or degloving.

 Polytrauma
For damage control surgery in polytrauma
The safest way to achieve initial stabilization of fracture in the severly injured
Can be performed rapidly, minimal invasive technique minimize any additional surgical insult to the patient
 Articular fractures
Recommended in case of open or closed articular fracture with severe soft tissue
compromise,when it can be applied in a joint bridging fashion
 Bone or soft-tissue loss
 External fixator as a tool for indirect reduction
One way to achieve minimally invasive intraoperative reduction is to apply the modular
external fixator as an external reduction device
TYPES
 Pin fixator
 Ring fixator
 Hybrid Fixator
Pin Fixator Ring Fixator

Components: Components
• Bone screw/Half Pins • Tensioned thin wires
• Clamps Olive or straight
• Central body- Connecting rods/tube • Wire and half pin clamps
• Compression-Distraction system • Rings
• Rods
• Motors and hinges
Construct design
Pins/Half pin/Schanz screw

 It is the critical link between bone and the frame

 Various diameter,lengths,and different tips
 Material- titanium and stainless steel
 Coating
non coated
Silver
Hydroxyapatite
 Many options
2-6 mm size
Self drilling/taping
Blunt tip
Conical
Fine thread
Course thread
Pin Diameters

 The single most important factor with frame strenghth is increasing pin
size
 Pin stiffness is proportional to radius4
 5mm pin is 144% stiffer versus 4mm pin

General Guidelines
Femur – 5 or 6 mm
Tibia – 5 or 6 mm
Humerus – 5 mm
Forearm- 4 mm
Hand, foot – 2.5- 3 mm
 For definitive fixation,

Placing one pin as close to the fracture as

possible,
Another pin placed as far as possible within
same bone
 For provisional stabilization,

Potential areas for future definitive fixation

should be considered and avoided,
Prevent the occurrence of deep infection arising
from pin tracts
Clamps

 2 general varieties:
Single/multiple pin to bar clamp
bar to bar clamp
 Priniciples:
Must securely hold the frame to the pin
Clamps placed closer to bone increase the stiffness of the entire fixator construct
Connecting Rods and/or Frames

 Materials
Steel
Aluminium
Carbon fibre
 Design
simple rod
Articulated
Telescoping
 Principle
Increaed diameter = increase stiffness and strenghth
Stacked/2 parallel bars = increased stiffness
Frames with carbon fibre are stiff but weak link is clamp to carbon bar
Ring Fixator

Components
 Tensioned thin wires
Olive or straight
 Wire and half pin clamps
 Rings
 Rods
 Motors and hinges
Principles
 Multiple tensioned thin wires (90-130kg)
 Place wires as close to 90o to each other
 Use full rings(more difficult to deform)
 Half pins also effective
 Can maintain purchase in metaphyseal bone
 Allows dynamic axial loading
 May allow joint motion
The stiffness of the frame depends upon the
following factors
• Distance of the pins/Schanz screws from the fracture focus: closer means stiffer
• Distance between the pins/Schanz screws inserted in each main fragment: further apart means stiffer
• Distance of the longitudinal connecting tube/bar from the bone: closer means stiffer
• Number of bars/tubes: two are stiffer than one
• Configuration (low to high stiffness): uniplanar/A-frame/biplanar
• Combination of limited internal fixation (lag screw) with external fixation: only rarely indicated as mixing
elastic with stable fixation is for temporary use only
• Thickness of Schanz screws or Steinmann pins—6 mm vs 5 mm pins (double bending stiffness)
Construct Design

 Bilateral v/s Unilateral

Stiffer
Can be cumbersome to apply
Hold a higher potential for pin infection
 Uniplanar v/s Multiplanar

Less obstructive for soft tissue access but are 4-7 times
weaker
 Pins and bar should be aligned with the bending axis of the bone.
 Fixator used for oblique fractures,placing angled pins parallel to the fracture line to create a
structural parallelogram is more effective at reducing shear than is the use of transverse pins.
Construct Design

 Insufficiently stable external fixation may delay fracture healing

and lead to pin loosening.
 Too much stiffness or rigidity of external fixator construct may
also delay fracture healing.
 In the management of such fracture it may be necessary to
dynamize an initially quite stable configuration or add stability in
case of pin loosening
 Dynamization

 External fixator constructs can be partially loaded from the very

beginning
 As healing progresses, the load is increased until full weight
bearing is achieved
 Partial and full weight bearing under external fixation is the best
and most effective method of dynamization.
Hybrid fixator

 Combines advantages of ring fixator with simplicity of planar half

pin fixator in diaphyseal bone
 Pin insertion technique

When inserting a Steinmann pin or Schanz screw the following is important:

 Know the anatomy and avoid nerves, vessels, and tendons
 Do not place pins or screws into a joint
 Avoid the fracture focus and hematoma
 Avoid degloved and contused skin
 Predrill the cortex to avoid burning the bone (ring sequestrum is produced)
 Insert a Schanz screw of the correct length to allow appropriate frame construction
Timing of procedure

 1. All pin sites must be clean if new internal fixation is placed around old sites of
external fixation. Sometimes this requires 2-stage surgical procedures to first clean the
old pin sites followed by the definitive fixation procedure.
 2. Any pin sites more than 10–14 days are assumed to be colonized and should go
through a sterile cleaning and debridement procedure before definitive fixation is
placed near these sites.
 3.If there is any doubt about the sterility of these pin sites, or if they have been frankly
infected, then a “pin holiday” of at least 10 days is used after a sterile debridement
procedure before placing new internal fixation.
 4. Prophylactic antibiotics must be administered and cover the bacteria responsible for
any previous pin-site infections.
 5. Close postoperative follow-up is performed during the first 6 weeks