External fixator

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 External Fixator

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

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

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Keetley 1893, Ollier,
Roux
History

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 Parkhill 1894
Threaded pins and
clamp
History

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

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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.
In 1948, Charnley popularized his compression
device to facilitate arthrodesis of joints.
History

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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.


History

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Today's Fixators

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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
Types

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Biomechanics of External Fixator
 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.

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Thus Stiffness is inversely proportional to the
distance of the assembly from the bone
(closer the frame to bone -more stable
assembly)
Biomechanics

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Mechanics of Bone Pin Interface

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

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A. Schanz screw
4. 5 short threaded for diaphysis
5 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

Basic Components

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Basic Components

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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 screw.
Required instruments

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Required instruments

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

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

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External fixation of the tibia is advocated in
severe open fractures (Gustilo 3b,3c)
closed fractures with severe soft-tissue injury
open fractures involving bone loss
compartment syndrome after fasciotomy
adjunct to internal fixation
limb lengthening or bone transport
Indications

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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.
External fixator as temporary device

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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.
External fixator as temporary device

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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.
External fixation as final fixation

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External fixation as final fixation

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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
Advantages

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Pin Track Infection.
Neurovascular Impalement.
Muscle or Tendon Impalement
Delayed Union.
Compartment Syndrome
Re-fracture
Limitation of further Alternatives.
Cosmetic Problem
Complications

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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”.

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Open fracture Tibia and Fibula
Open fracture Femur
Floating Knee
Open Fracture Humerus
Communited fracture distal Radius
Pelvic fracture.
Site of insertion

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Tibial Safe Zone
Proximal part of the proximal tibia

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Tibial Safe Zone
Proximal 3
rd
distal to tibial tuberosity

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Tibial Safe Zone
Mid Shaft

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Tibial Safe Zone
Distal 3
rd
distal of tibial Shaft

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Schanz screw insertion

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Schanz screw insertion for Metaphysis

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Technique of Applications
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.

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 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.
Technique of Applications

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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.
Technique of Applications

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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 Screw with
T-handle.
Technique of Applications for metaphysis

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Place the most distal
Schanz screw using
the standard
technique.
Place a universal
clamp onto the schanz
Fix a 11mm tube in
this clamp, so that it
is posterior to the
schanz screw.
Application of external fixatorApplication of external fixator

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Slide 3 Universal
clamps onto this tube.
Insert most proximal
schanz screw.
Reduction of bone.
Fix the proximal
schanz screw.
Application of external fixator…Application of external fixator…

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 Insert the 3
rd
4
th

schanz screw
accordingly.
Connect frame with
another Tube.
Second tube is
clamped in “mirror
image” fashion after
prestressing.
Application of external fixator…Application of external fixator…

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In the OT

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In the OT
Open fracture Gustilo IIIB with Fixator

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In the OT
Flap Coverage

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Ilizarov External Fixator.
Universal Mini Fxternal Fixator.
Modular external Fixator
Other External Fixators

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Ilizarov External Fixator.

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Ilizarov External Fixator.

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Ilizarov External Fixator.

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Universal Mini External Fixator
Micro-motion at fracture Site.
 It is bi-lateral
More lighter than traditional External Fixator.
More ligamentotasis
Less chance of pin tract infections.

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UMEX

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Modular variety of External Fixator
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.

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Modular variety of External Fixator

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Other variety of External Fixator
Synthes Adjustable Tibial exfix
Hoffman II external fixation system

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Conclusion
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.

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References
Course manual: The 3
rd
Annual Fracture fixation Course;
Eastern India Initiative for Orthopaedic Training
Uses of External Fixator in orthopaedic surgery; Dr. ABM
Golam Farque; a Power Point Presentation.
Wheeless' Textbook of Orthopaedics
http://www.wheelessonline.com/ortho
Synthes: leading global medical device company.
http://us.synthes.com/
AO Foundation. <www.aofoundation.com>

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Thank YouThank You