Principios de Fijacion Externa

Principles and 8
Complications of External
Skeletal Fixation
Stuart A. Green | Wade Gordon
Additional videos related to the subject of this chapter are in large dogs5—and the external fixator of Swiss physician
available from the Medizinische Hochschule Hannover Raoul Hoffmann (1938)6 (Fig. 8.2).
collection. Several of these devices saw use during World War II.
The following videos are included with this chapter and Toward the end of that cataclysm, however, the high incidence
may be viewed online at Expert Consult: of complications associated with external fixation became
8.1. The modular technique of applying external fixation.

8.2. Taylor Spatial Frame.
HISTORICAL BACKGROUND
EARLY FIXATORS
The external fixator was invented 12 years before the plaster
cast. In 1846 Jean Francois Malgaigne devised an ingenious
mechanism consisting of a clamp that approximated four
transcutaneous metal prongs to reduce and maintain patellar
fractures1 (Fig. 8.1). In the 170 years since Malgaigne’s
invention, many other external fixation systems have been
introduced. Among the best known are the Parkhill bone
clamp (1897),2 Lambotte’s monolateral external fixator
(1902),3 Roger Anderson’s 1934 fixation system,4 the 1937
Stader apparatus—originally developed for managing fractures
Fig. 8.1 Malgaigne’s 1846 external fixator for patellar fractures.
A B C D E
Fig. 8.2 Historic external fixators. (A) Parkhill bone clamp. (B) Lambotte fixator. (C) Anderson apparatus. (D) Stader apparatus. (E) Hoffmann
fixator.
207
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208 Section ONE — General Principles
apparent. The major disadvantages noted by a military of complications with their techniques, some of which are
commission who studied the matter included nerve and unique to limb lengthening.14
vessel injuries by pins, the presence of soft tissue infections In Russia, external fixation as a modality for fracture
at the pin sites, the possibility of ring sequestra and osteo- treatment remained viable in the period subsequent to
myelitis, and the danger of delayed union or nonunion. World War II. Surgeons in that country focused attention
Other surgeons were distressed by the mechanical difficulty on ring-type fixators that were connected to the bone by thin
associated with external fixators, as well as by the prospect transfixion wires tensioned by special wire-gripping clamps.
of converting a closed fracture to an open fracture.2 As a Although these fixators were quite cumbersome, some
consequence, by 1950 most American orthopaedic surgeons contained ingeniously geared articulations that permitted
were not using mechanical fixators although the pins-in-plaster precise displacement of the rings in any of three planes
technique was used for special problems, such as unstable independently.
wrist fractures7 and displaced fractures of the tibia and
fibula.8
CIRCULAR FIXATORS
In Europe, conversely, clinical research on external skeletal
fixation continued throughout the years during and after In 1951 Dr. Gavriil A. Ilizarov of Kurgan in the former Soviet
World War II. Raoul Hoffmann improved his device, providing Union developed the first model of his transfixion-wire
a stronger universal joint and an enlarged pin-gripper that circular fixator, which is still used today15 (see Fig. 8.3C).
held the pins more securely. Charnley, of England, presented Other Soviet surgeons subsequently designed similar devices,
his concept of compression arthrodesis of the major joints,9 some with geared couplers that allowed gradual repositioning
using a rather simple skeletal fixator that provided continuous of bone fragments. Within a few years, Ilizarov discovered
compression of cancellous surfaces of the joint to be fused. that bone would form in a widening distraction gap under
In time, the Arbeitsgemeinschaft für Osteosynthesefragen appropriate conditions of stability, delay, and distraction.16
(AO) group of Switzerland modified Charnley’s device to His observations and subsequent clinical research revolu-
more pins in his frame configuration.10 tionized deformity correction and limb salvage surgery and
Also in France during the 1960s, Jacques Vidal and cowork- contributed to a revived worldwide interest in circular external
ers used Hoffmann’s equipment but designed a quadrilateral fixation.17
frame to provide rigid stabilization of complex fracture Ilizarov’s apparatus consists of separate components that
problems and septic pseudarthroses under treatment11 can be assembled into an unlimited number of different
(Fig. 8.3A). configurations that allow a surgeon to perform all of the
following:
FIXATORS FOR LIMB LENGTHENING
• The percutaneous treatment of all closed metaphyseal and
External fixators specifically designed for limb lengthening diaphyseal fractures, as well as many epiphyseal fractures
began to appear after W. V. Anderson developed an apparatus • The repair of extensive defects of bone, nerve, vessel, and
that employed full transcutaneous pins connected to threaded soft tissues without the need for grafting—and in one
bars.12 The device permitted gradual distraction of an oste- operative stage
otomized bone. Heinz Wagner,13 working in Germany, • Bone thickening for cosmetic and functional reasons
modified Anderson’s concept even further, substituting • The percutaneous one-stage treatment of congenital or
half-pins for Anderson’s full pins, while employing a universal traumatic pseudarthroses
distraction bar that patients could lengthen themselves (see • Limb lengthening or growth retardation by distraction
Fig. 8.3B). These pioneers accurately recorded the incidence epiphysiolysis or other methods
A B C
Fig. 8.3 Modern external fixators. (A) Vidal quadrilateral frame. (B) Wagner limb lengthener. (C) Ilizarov apparatus.
CHAPTER 8 — Principles and Complications of External Skeletal Fixation 209
• The correction of long bone and joint deformities, includ- These fixators, which are often referred to as hybrid designs,
ing resistant and relapsed clubfeet usually combine an Ilizarov-type ring with an AO-type tubular
• The percutaneous elimination of joint contractures bar. The tensioned wires are secured to the ring (which
• The treatment of various arthroses by osteotomy and surrounds the cancellous portion of the bone) while the
repositioning of the articular surfaces bar connects to half-pins in the cortical bone.
• Percutaneous joint arthrodesis Ring fixators have a distinct advantage over unilateral or
• Elongating arthrodesis—a method of fusing major joints bilateral devices because the apparatus—especially Ilizarov’s
without concomitant limb shortening device—permits a surgeon to gradually reposition fracture
• The filling in of solitary bone cysts and other such fragments (or osseous fragments after osteotomy) with respect
lesions to each other in three-dimensional space. To match this
• The treatment of septic nonunion by the favorable effect capability, several new unilateral fixators incorporate geared
on infected bone of stimulating bone healing articulations that permit the controlled movement of one
• The filling of osteomyelitic cavities by the gradual collapsing pin-gripper with respect to the others.
of one cavity wall
• The lengthening of amputation stumps
FIXATORS FOR SEVERE TRAUMA
• Management of hypoplasia of the mandible and similar
conditions One modern concept of care for severe polytrauma starts
• The ability to overcome certain occlusive vascular diseases with the application of a simple external fixator for prelimi-
without bypass grafting nary stabilization of each seriously injured limb, followed by
• The correction of achondroplastic and other forms of more definitive reconstruction later on.21 The goal of most
dwarfism surgeons who apply a fixator for the temporary stabilization
of a limb is to convert from external fixation to internal
An American orthopaedist David Fischer visited Moscow fixation, usually an intramedullary nail. The concept is
in 1975 where he obtained several different Soviet circular discussed at length later in the section, “Using the Atlas for
external fixators. After applying these frames to his own Damage Control Orthopaedics.”
patients, he became concerned with the problems of frame Although a number of protocols have been recommended
instability associated with transfixion wires, as well as the to reduce the likelihood of such an infection, one promising
perceived weight of the circular frames he tried. Thereafter, concept has been the development of a “pinless” external
Fischer developed a circular fixator, which attached to bone skeletal fixator by the AO group. With this device, a spring-
via full pins and half-pins.18 The entire system was originally loaded pair of pins that resemble ice tongs, which grip the
fabricated from titanium—a lightweight yet strong metal. In cortex but do not penetrate into the endosteal surface,
general, he noted fewer pin-site infections when his device secures bone fragments. In this manner, the medullary
was mounted with titanium pins instead of steel implants. canal is (in theory, at least) free of microbial contamination.
Moreover, when titanium pin-site sepsis did occur, the Time will tell if such an invention reduces the incidence
reaction was more benign appearing, with far less cellulitis of implant sepsis when an intramedullary nail replaces an
and soft tissue reaction than was commonly observed with external fixator.
steel pins. A complete understanding of the ideal milieu for rapid
North American orthopaedic surgeons, exposed to Ilizarov’s fracture healing has yet to be ascertained. Around the world,
methods by Italian practitioners in the mid-1980s, modi- pioneering clinicians and researchers are using fixators to
fied Ilizarov’s technique. Among the most useful of these study the influence of stability, distraction, and compression
improvements has been the fabrication of rings and plates on fracture healing and regenerate new bone formation.
of the Ilizarov apparatus from radiolucent carbon fiber. This The results of these studies will certainly advance the clinical
material, though more expensive than steel, is substantially applications of both internal fixation and external fixation
lighter and thus popular with the patients. and improve fracture care in general.
At Rancho Los Amigos Medical Center, the author and When trauma surgeons discovered in the mid-1980s
his coworkers began using titanium half-pins (in place of that open fractures could safely be treated with intra-
steel wires) to secure Ilizarov’s circular fixator to long bones medullary nails, it appeared that external fixation’s role
requiring either limb lengthening or deformity correction.19 in orthopaedic surgery would be greatly diminished.
In this manner, the adaptability of the circular device was Ilizarov’s discovery of distraction osteogenesis, however,
retained, but the problem of muscle impalement and trans- has rendered the prediction of external fixation’s demise
fixion was reduced, especially in bones such as the ulna premature indeed. Fixators have become an important part
or tibia that have large subcutaneous surfaces. In certain of deformity correction, especially where limb elongation
anatomic locations, however, wire mounts still appeared is a concomitant requirement. For this reason, worldwide
superior to pin mountings—especially in the juxtaarticular use of external skeletal fixation is on the rise again, as it
regions where cancellous bone predominates. For more was before World War II and again in the 1970s and early
substantial fragments that include both the articular and 1980s.
metaphyseal regions, combinations of pins and wires have
proven successful for mounting circular external skeletal
COMPUTERIZED CORRECTION
fixation.20
Several new fixator configurations have been devised specifi- In the 1990s Dr. Charles Taylor—codeveloper of the Russell-
cally for applications that require anchorage in cancellous Taylor intramedullary nail—realized that the reduction of a
bone at one end of the frame and cortical bone on the other. displaced bone fragment (or correction of a deformity) could
be accomplished by mathematically defining the path a bone its developers and manufacturers as the next step in deformity
fragment travels as it moves from its displaced position to correction technology. Time will tell if a true advance has
its corrected position.22 Using an ingenious design, Taylor occurred.
connected rings of an Ilizarov-type circular fixator to one The disruptive technology in the field of reconstructive
another with six struts, each of which could be independently limb surgery, however, is the introduction of intramedullary
lengthened or shortened (Fig. 8.4). In this way, the relation- lengthening nails that reliably elongate in response to an
ship between the rings can be altered in a precise manner, externally applied force, either electrical, magnetic, or
modifying the relationship of the rings—and their attached mechanical. The expanding indications and application of
bone fragments—to one another.22 this technology are covered in depth in a separate chapter
After measuring the precise displacement of the bone in this book.
fragments and the relationship between the fragments and
their respective rings, the data are fed into a computer that
COMBINED INTERNAL AND EXTERNAL FIXATION
has been programmed to determine the pathway to reduction
in all planes—angulation, rotation, shortening, and transla- Certain additional developments have occurred since the
tion.23 Moreover, the computer program outputs a schedule previous edition of this book. External fixation is now fre-
of strut length changes needed to effect the reduction at quently combined with internal fixation to reduce the total
whatever predetermined speed is needed for both safety time and external fixation frame.25–27 This strategy not only
and efficacy. The system, called the Taylor Spatial Frame, is reduces patient discomfort and problems with activities of
quite popular with surgeons who have become familiar with daily living, but also reduces the incidence of pin tract infec-
its use (see Video 8.2).24 tions, which rises slowly but steadily during the time a fixator
Since the previous edition of this book, the patent on the is in place. This evolution started with lengthening over an
Taylor Spatial Frame’s computer interface expired, a fact intramedullary nail, a strategy devised in the Baltimore
that has led to the introduction of several hexapod systems protocol by Paley and coworkers,28 whereby an intramedullary
with surgeon-friendly computer interfaces, each lauded by nail is inserted into a bone after osteotomy for limb elonga-
tion. During the same operative session, an external fixator
is applied to the limb with care to avoid contact or even
close proximity of the transosseous implants with the intra-
medullary implant. This requires careful fluoroscopy-
controlled pin or wire insertion.
Typically, pins or wires are inserted from the posterior to
the implant in the femur and tibia, although anterior place-
ment is also acceptable. This strategy is particularly appealing
to patients who can have the fixator removed and transverse
locking screws inserted into the limb as soon as the distraction
phase of the treatment protocol has been completed. There-
after, ordinary weight bearing, usually with ambulatory aid
support to protect the implant, continues until the regenerate
bone forms around the implant.
Two comparable strategies have evolved in recent years,
both coming from the group at the Hospital for Special
Surgery in New York.29,30 The first is lengthening and then
nailing, a strategy that starts out with a typical Ilizarov-type
lengthening that would consist of either a classic ring fixator
or a modified ring fixator, such as the Taylor Spatial Frame
(particularly if there is concomitant deformity correction),
or even a multilateral fixator. Once the deformity is fully
corrected and the bone is straight, with early regenerate
formation in the distraction gap, an intramedullary nail is
inserted and secured with transverse locking screws, and the
fixator is removed. Obviously, the transcutaneous transosseous
implants must be inserted in a place far enough away from
the anticipated medullary canal passage of the nail to prevent
contamination by microbes in the pin or wire tract.29,30
Another strategy from the same facility involves the use
of external skeletal fixation to achieve length, followed by
the use of a plate and screws to shorten the fixator time once
the final position of the bone has been achieved.29 The advent
Fig. 8.4 The Taylor Spatial Frame. Six adjustable struts control the
relationship between the two rings, one of which must be mounted of locking plates makes such a strategy possible, because the
orthogonal to either the proximal or distal fragment. All deformity and plate often has to span a zone where the regenerate new
mounting parameters are fed into a computer, which calculates the bone is very weak, sometimes only a wispy shadow, thus
strut length changes needed to restore the displaced fragment to requiring a particularly strong and stable plate and screw
anatomic alignment. fixation (see Video 8.1).
Alternatively, implants are being developed that consist

FIXATOR-ASSISTED NAILING
of bone plates containing self-lengthening mechanisms,
With certain kinds of periarticular osteotomies, such as a permitting both deformity correction and limb elongation
high tibial osteotomy or distal femoral osteotomy, precise with one operation. Although the cost of such implants may
control of the osseous fragments is essential to a successful limit their use to the more affluent nations, the ability to
outcome. Where internal fixation, particularly intramedullary simultaneously lengthen and realign a limb without the use
fixation, is employed to secure the fragments, it is helpful of external skeletal fixation is clearly appealing.
to use a temporary external skeletal fixator for alignment What then will be the role of external skeletal fixation
after osteotomy, but before inserting the definitive implant. when such devices become available? Certainly, damage-
In this case, as with lengthening over a nail or lengthening control orthopaedics employing temporizing fixators will
and then nailing, the transcutaneous transosseous implants continue as a strategy for initial trauma management.31
must be situated in a way that does not block placement of Likewise, fixator-assisted surgery will continue to play a
the definitive hardware. However, unlike situations where role where precise correction of a deformity before apply-
the fixator will be left on for some protracted period of time, ing any internal fixation plate or intramedullary nail is
temporary application of a fixator in the operating room required.
(OR) for alignment purposes does not risk implant-site sepsis A bewildering variety of fixators possessing ingenious
where the transcutaneous pins or wires come in contact with articulations and pin-grippers are currently available. Surgical
the definitive implants. Therefore the technique is particularly appliance manufacturers continue to add new components
appealing where precision is required. and fixator frames to the marketplace at a steady pace, even
as the demand for external fixators may diminish in the
future. The devices vary considerably in configuration and
EXTERNAL SKELETAL FIXATION IN THE FUTURE
in technique of frame assembly. The feature common to all
Profound changes in implant technology will soon cause a fixators, however, is that they are attached to the human
paradigm shift in the use of external skeletal fixation. Self- body with pins or wires that penetrate the skin and affix to
lengthening intramedullary nails will stimulate the change. bone. The complications associated with transcutaneous pins
Initially, such devices used mechanical methods to elongate. are thus common to all past, present, and future fixators,
Specifically, a ratchet mechanism within the device caused regardless of design or construction. Reducing pin-site sepsis
the implant to lengthen when the proximal portion of the will, more than any other measure, ensure the continued
nail was rotated with respect to the distal portion. Three development of external skeletal fixation.
nails using this strategy, the Bliskunov, the Albizzia, and the
intramedullary skeletal kinetic distractor (ISKD),31 all had
the same drawbacks. Because these implants elongated with FIXATOR TERMINOLOGY
limb rotation, they would sometimes lengthen too fast,
particularly if the patient was too active with the device in Pin: The term pin refers to that portion of the fixator that
place.32,33 Conversely, if the distraction proceeded too slowly, penetrates the skin and soft tissues and attaches to bone. In
early hardening of the regenerate new bone would prevent the European literature, pins are sometimes referred to as
counterrotation of the fragments, necessitating a return trip screws or nails (the distinction resting perhaps on the presence
to the OR for osteotomy of the regenerate.34 or absence of threads).
The second generation of self-lengthening nails uses Full pin: A full pin is one that protrudes through the skin
internal rotating components and threaded spindles to motor and soft tissues on both sides of the limb. Such pins are
the elongation. In one case, the Fitbone, an electric motor sometimes referred to as transfixion pins or through-and-through
energized through a subcutaneous induction coil, powers pins.
the lengthening.35,36 A rotating magnet, responding to external Half-pins: A half-pin is one that penetrates the skin and
magnetic fields, elongates both the Phenix and the Precice soft tissues on one side of the limb only and that penetrates
intramedullary nails. The devices are so new that a body of bone but does not emerge on the other side of the limb.
literature does not exist yet that supports their use. When inserted, such pins are supposed to penetrate both
These self-lengthening implants allow gradual limb elonga- cortices of the bone but not much beyond the second
tion without the use of bulky external skeletal fixation. cortex.
Likewise, the absence of transcutaneous implants associated Wire: A thin transosseous implant, usually less than 2 mm
with fixators greatly reduces patient discomfort with internal in diameter, which is not stiff enough to provide stability to
lengthening devices. Moreover, pin tract infections are a a fixator-bone configuration until tensioned and bolted to
thing of the past with self-lengthening nails. the fixator. For this reason, most wires must penetrate the
At present, none of the internal lengthening implants entire limb and be secured to the fixator at both ends.
can achieve active deformity correction as part of the Olive wire: A wire with a bead somewhere along its length,
elongation process. However, a new strategy combining which prevents the wire from being pulled through the
wedge resection and deformity correction (often stabilized bone. An olive wire can be employed to pull bone frag-
with plates and screws) with a self-lengthening nail will ments into position or to enhance stability of the bone-fixator
eliminate the use of external skeletal fixation for substantial configuration.
limb deformities. Instead, the deformity will be corrected Pin-gripper: The device that holds the pin to the rest of
and secured with internal fixation until the fragments the fixator.
unite. Thereafter, a self-lengthening nail will restore Bar: A part of the apparatus that connects the pin-grippers.
limb length. Bars may be solid or hollow, smooth or threaded, and they
may incorporate a compression-distraction apparatus in their

structure.
Ring: A circular bar (or modified bar) that attaches to
pin-grippers in a plane that is usually perpendicular to the
long axis of the limb. The rings may or may not completely
encircle the limb. (Incomplete circles are called half-rings.)
The rings must be connected to each other by bars to create
a fixator configuration.
Articulations: A device that connects one bar to another
(or a bar to a ring). Some articulations consist of universal
joints or hinges, but most do not.
FRAME CONFIGURATION A B
Throughout this chapter, frame configuration terminol-

ogy modified from Chao and coworkers78 will be used
(Fig. 8.5).
Unilateral: The unilateral frame is one that employs one
bar connecting two or more pin-gripping clamps, which are
attached to half-pins. It is the simplest configuration. This
category includes Parkhill’s original bone clamp, Lambotte’s
external fixator, and the apparatuses devised by Stader,
Hoffmann, and Wagner.
Bilateral: A bilateral frame is one that employs a rigid bar
on both sides of the limb, connected to full pins that transfix
the bone. Roger Anderson’s external skeletal fixator was of
bilateral design.
Biplanar or multiplanar: A biplanar or multiplanar frame
is one that employs pins in two or more planes for increased C D
stability.
Ring: A ring fixator is one that uses transverse bars
that completely encircle the limb. Pins transfix the limb
and connect to the rings in various locations. Additional
bars, as noted earlier, connect the rings to each other.
Russian investigators have been using these fixators for
many years.
Half-ring: A half-ring fixator is one employing bars that
incompletely encircle the limb in a manner similar to the
ring fixator.
PREFABRICATED FIXATORS
External fixation systems in which a manufacturer prefabri- E F
cates the components can be divided into two broad categories: Fig. 8.5 Basic fixator configurations. (A) Unilateral. (B) Bilateral. (C)
those with fixed configurations and those with variable Multiplanar (quadrilateral). (D) Multiplanar (delta configuration). (E) Ring
configurations. fixator. (F) Hybrid fixator.
Fixed configuration: These external fixation frames are
characterized by a relatively fixed, but usually adjustable,
spatial configuration that dictates the position, direction, or
number of transcutaneous pins. unsolidified substance that hardens within a few minutes
Variable configuration: The variable configuration fixator after being applied. The classic pins-in-plaster technique,
systems are similar to one another in that they consist of methylmethacrylate external pin fixation, and epoxy-filled
many separate components that can be assembled into any tube systems belong in this group. These systems permit
spatial configuration as dictated by the nature of the unlimited pin positions, but they lack adjustability and
musculoskeletal problem. Precise pin position is generally preclude compression or distraction.
required only with the individual pins within a cluster (those
held by the same pin gripping clamp).
PROBLEMS, OBSTACLES, AND
IMPROVISED FIXATORS COMPLICATIONS
This category comprises systems of external fracture man- The application of an external skeletal fixator, especially
agement where transcutaneous pins are connected to an one that involves the slow repositioning of bone fragments,
is different from most other surgical procedures because the

VESSEL INJURIES
“operation” does not end when the patient leaves the OR.
Instead, the procedure stretches out over many months, with When vascular injuries do occur, they sometimes present in
many clinic visits needed to follow the progress of the bone a most peculiar way.41 A pin directed at a vessel will usually
fragments. As will be evident from the following discussion, push it to the side without transecting it42 (Fig. 8.6A). As
pin tract infections, numbness from nerve stretching, delayed time passes, the vessel, resting against the pin, develops an
union, deviation of mechanical axis during elongation, and erosion in its wall. As a result, the patient may suddenly
numerous other difficulties occur during a typical case. To experience bleeding from the implant hole quite some time
call all of these challenging events “complications” leads to after fixator application43 (see Fig. 8.6B). Alternatively, the
the conclusion that external fixator applications have a 500% pin may create a hole in the side of a vessel, which does not
complication rate. Many practitioners who do large numbers become apparent until the pin is removed. Excessive bleeding
of fixator applications use a scheme of analysis popularized through the pinhole may occur44 (see Fig. 8.6C), or a false
by Paley that includes problems, obstacles, and complica- aneurysm may develop in the soft tissues. If the vessel wall
tions.38 Problems in this paradigm are those difficulties that necrosis involves an adjacent artery and vein, an arteriovenous
are correctable in the clinic, often by either a modification fistula may be created shortly after pin removal.
of the mounting parameters or a prescription medication. Reports describing serious distal vascular compromise after
Obstacles are those difficulties that require a return trip pin insertion are also rare, perhaps because collateral circula-
to the OR for correction, including repeat osteotomy for tion is usually adequate to sustain the limb. In those few
premature consolidation, pin or wire replacement for cases where a limb becomes ischemic after pin or wire
sepsis or loosening, or even a bone graft for tardy bone insertion, severe trauma usually preceded fixator application,
healing. True complications in this scheme are the perma- suggesting loss of collaterals.
nent sequelae of treatment that adversely compromise the One location in particular may be subject to frequent yet
outcome. This includes permanent nerve injury, persistent undetected neurovascular injury—the distal lateral tibial
infection, failure to obtain union, and so forth. This three- surface. In that location, Raimbeau and coworkers45 analyzed
level perspective more correctly describes the entire external damage to the anterior tibial artery caused by transcutaneous
fixation encounter and allows comparison to other methods pins. They performed arteriograms on cadaver limbs and
of treatment. determined that the region of the tibia between the lower
end of the third quarter and the upper end of the fourth
quarter is a danger zone for transfixion pin placement because
NERVE AND VESSEL INJURY the anterior tibial artery and deep peroneal nerve lay directly
on the tibia’s periosteum (Fig. 8.7).
Reports of serious neurovascular injury from fixator pins
and wires are surprisingly uncommon. In fact, workers report-
COMPARTMENT SYNDROME
ing large series of external skeletal fixator applications usually
note the absence of a significant nerve or vascular injury. On rare occasions, external fixation pins have been blamed
However, they are not unheard of, and descriptions of such for causing anterior tibial compartment syndrome.42,46,47
injuries do appear from time to time in reports dealing with Raimbeau and his associates also measured tissue pressures
external skeletal fixation.39,40 in the anterior compartment after insertion of transcutaneous
C
Fig. 8.6 (A) A pin or wire directed at a vessel will often push the structure to the side. (B) A vessel resting on an implant may erode and bleed
2 or more weeks after implant insertion. (C) Alternatively, bleeding may occur at the time of implant removal.
are inserted into certain anatomic areas, such as the lateral

humerus or proximal radius. Instead of exposing these
structures surgically, however, one can select pin placement
positions that avoid the possibility of damage to these
structures.
Two difficulties are encountered during pin or wire inser-
tion that could lead to a nerve or vessel injury. First, the
surgeon is occasionally unsure of the precise position of a
major nerve or vessel with respect to the bone at the level
of the limb selected for implant insertion. This confusion
arises from the surgeon’s orientation to the local anatomy,
which usually considers the position of a nerve or vessel in
its longitudinal relationship to surgical exposure. Indeed,
surgical exposures are purposefully parallel to both the bone
and the neurovascular structures in each anatomic region.
Second, it is frequently difficult to assess the exact depth to
which a pin has penetrated into the bone. This may seem
surprising, considering how easy it is to “feel” when a drill
bit penetrates the opposite side of a bone during drilling.
Nevertheless, because the pin is threaded, there is enough
resistance to forward progress to make depth determination
difficult.
IMPLANT PLACEMENT TO AVOID

NEUROVASCULAR INJURY
An atlas showing pin placement positions designed to reduce

the likelihood of neurovascular injury from transcutaneous
implants appears in this chapter.41 By recommending pin or
Fig. 8.7 The danger zone for implants is one fingerbreadth above
and two fingerbreadths below the junction of the third and fourth
wire placement in certain positions, I do not mean to imply
quarter of the tibia where the anterior artery and deep peroneal nerve that these are the only acceptably safe positions for insertion.
lay directly on the bone’s lateral surface. At many points in the limb, pins can be safely inserted in
several directions that have not been indicated. The descrip-
tions of these positions were omitted for the sake of simplicity
and clarity of illustration. With experience (and reference
to the atlas), surgeons will find additional pin positions to
solve specific clinical problems
pins.45 They determined that the intracompartmental pressure In selecting the recommended direction for inserting
was not significantly elevated after insertion of one transfixion a pin, I followed several principles designed not only to
pin, but it more than doubled when a second pin was inserted. reduce the incidence of neurovascular injury but also to
Insertion of a third pin did not significantly raise the pressure allow easy, yet solid, pin insertion. First, whenever possible,
any higher. Thus they identified two vascular syndromes the pins are inserted perpendicular to the bone surfaces.
associated with pin fixation of the lower leg. The first, interfer- This facilitates the pin insertion process because it reduces
ence with the distal circulation of the anterior tibial artery, the tendency of the pinpoint to “walk” (slide along the bone
is quite rare because adequate collateral circulation is usually surface). The tibia, for example, has a triangular cross section.
present. The second, anterior compartment syndrome, may When the patient is supine, the lateral surface is vertical
also be due to partial occlusion of the anterior tibial artery and the medial surface is oblique. Full pins are more easily
combined with the increased compartment pressure associated inserted from lateral to medial because of this anatomic
with transfixion pins. feature.
Second, pin directions should cross the center of the
medullary canal to engage both cortices. When widely sepa-
NERVE INJURIES
rated cortices are engaged by a pin, the tendency of the pin
Acute transection of a major nerve is unlikely with external to wobble and loosen is reduced and maximum stability of
skeletal fixation. Nerves may, however, be nicked during the pin fixation is achieved.
course of pin insertion, or, more commonly, stretched during Third, pin insertion into dense bony ridges is to be
limb lengthening or bone transport.39,40 avoided wherever possible. Drilling into very dense cortical
In spite of the relative infrequency of reports of serious bone with hand tools is tedious and frustrating, tempting
neurovascular injury, great care is nevertheless required the surgeon to try to overcome the resistance by pushing
during pin insertion so that major neurovascular structures harder and drilling faster, which increases thermal injury
are not stretched or damaged. I recommend a skin incision, to bone and consequently the likelihood of pinhole
with observation of major neurovascular bundles, when pins sepsis.
Fourth, pin positions should have a margin of safety on danger to neurovascular structures. Also, “backing out” a
the opposite side of the bone. A pin is considered “safe” if pin reduces its fixation in bone. When the depth of the first
it passes through the bone and emerges from the opposite pin is satisfactory, additional pins of the same length can be
side of the limb without encountering a major neurovascular inserted to the same depth. This strategy for pin insertion
structure. Such pins are illustrated as full (through-and- can also be employed to reduce radiograph exposure to the
through) pins, although wires or half-pins could, of course, OR personnel when image intensification fluoroscopy is used.
be safely inserted from either direction. Only a brief exposure is necessary to determine the position
A pin is labeled “caution” if a major nerve or vascular and depth of the first pin. Thereafter, pins can be inserted
structure is located on the opposite side of the bone at a to the same depth without checking the progress of each
distance equal to or greater than the diameter of the bone pin individually.
itself. In this respect, the designation refers only to half-pin The cross-section atlas in this book was specifically created
placement. A full pin may be labeled caution if the direction to aid the surgeon in the OR. Proper orientation of the
or angle of pin insertion is critical to avoid neurovascular cross-sectional diagrams to a patient on the operating table
injury. depends on the location of easily palpable landmarks. Each
A pin is labeled “danger” if a major neurovascular struc- limb section in the atlas is treated in an identical manner.
ture is between one-half and one bone diameter away from Each anatomic area is divided into four equal zones. Palpable
the bone on its opposite side. It is wise to insert such pins bony landmarks identify the upper and lower limits of each
under radiographic or fluoroscopic control. A pin is also anatomic area under consideration.
considered a danger pin if it must be inserted adjacent to In the thigh, the proximal bony landmark is the lateral
a neurovascular structure on the near side of the bone. prominence of the greater trochanter of the femur; the distal
Generally this requires open pin insertion—a longitudinal landmark is the lateral prominence of the lateral epicondyle
incision to identify the location of the structure before pin of the femur.
insertion. In the lower leg section, the proximal landmark is the
Pin placement is measured in degrees, rotating around medial tibial joint line; the distal landmark is the medial
the bone from anterior to posterior, with the center of the prominence of the medial malleolus.
bone always presumed to be the center of pin placement. In the upper arm, the proximal landmark is the lateral
Thus the direct anterior position is considered to be 0 degrees, prominence of the greater tuberosity of the humerus, which
and the direct posterior position is considered to be 180 is one thumb’s width below the lateral tip of the acromion
degrees. Pin placement from directly lateral to directly medial process. Distally, the landmark is the lateral epicondyle of
is considered to be 90 degrees lateral and a pin placed from the humerus.
directly medial to directly lateral is considered to be 90 degrees In the forearm, the proximal landmark is the lateral
medial. In the forearm where there are two bones available prominence of the radial head, which is one thumb’s width
for pin placement, the pin position for each is noted sepa- distal to the lateral epicondyle of the humerus. The distal
rately. The limb must be in the anatomic position during landmark is the lateral prominence of the radial styloid
pin insertion if the atlas is to be used correctly. The humerus process.
should be in neutral rotation, and the forearm supinated to
correlate with the location of the anatomic structures
TECHNIQUE OF IDENTIFYING LANDMARKS
indicated.
I recommend image intensification fluoroscopy for pin Each limb segment in the atlas is divided into four zones
or wire insertion. The correct assessment of the position and that are labeled A, B, C, and D, with A proximal and D
depth of the pin can best be determined if the pin is seen distal (Fig. 8.8). The zones approximate, but are not exactly,
in its true lateral projection. (In the true lateral projection the quarters of each limb segment. The atlas illustrates
of the pin, the central beam of the x-ray tube must be per- cross-sectional anatomy in the top, middle, and bottom of
pendicular to the pin itself.) At times, there is a tendency each zone. Key diagrams on each plate orient the reader to
by surgeons to judge pin position through use of an oblique the zones illustrated. For purposes of clarity, bones, nerves,
projection because a true lateral projection of the pins is arteries, and veins have been emphasized in relief. Muscle
difficult to obtain when the patient is supine on a large planes are indicated, but the muscle masses themselves are
operating table. The surgeon may have to use considerable not labeled. Small cutaneous nerves, veins, and muscular
ingenuity to position a limb for fluoroscopy with a C-arm branches of arteries have been omitted. Major arteries are
image intensifier. It may be necessary, for example, to rotate shown with one vein even if they are usually accompanied
the limb 45 degrees or more, while rotating the C-arm in by two venae comitantes. In the forearm, deep veins have
the opposite direction to obtain a true lateral projection. To been omitted completely. Some neurovascular structures
determine the exact location of a pin within a bone, it is are emphasized by making them slightly larger than
necessary to direct the central beam of the x-ray tube along natural size.
the pin itself. A perfect axial projection of the pin will result Many structures are labeled only once on each page, rather
in a small circular image equal to the diameter of the pin. than on each slice. Mental reconstruction of the zone will
In this manner, the position of the pin relative to the cortices fill in labels on the unlabeled slices. Unfortunately, some
can be determined. If roentgenograms rather than fluoroscopy anatomic features are not easily presented in cross-sectional
are used, the initial evaluation can be obtained after the first views. These are the transverse vessels and nerves that wind
pin is inserted to the presumed proper depth. Before the around the bone at one level. Furthermore, the atlas plates
roentgenogram is taken, it is safer to be too shallow than do not take into account variations in anatomy that can
too deep. If a pin is inserted too deeply, there is the obvious occur at any level. For these reasons, the atlas illustrations
charts an inaccurate procedure for determining the incidence

of pin tract sepsis.
For this reason, the concept of “major” and “minor” pin
tract infection was introduced, followed by other grading
systems using numbers or letters. Using such criteria, just
about every patient wearing an external fixator for more
Landmarks than a few weeks can expect at least one implant-site infection,
something that must be kept in mind when informing a
patient about a planned fixator application.
PATHOPHYSIOLOGY OF PIN- OR
WIRE-SITE SEPSIS
O.R. Towel FLUID SECRETION
A metallic pin—or most hard foreign substances for that
matter—when inserted into the body’s tissues will provoke the
development of a membrane separating the foreign material
from the adjacent tissues. If relative motion is present between
the foreign material and the local tissues, a bursal membrane
usually forms to secrete lubricating fluid. With a transcutane-
ous pin, however, the bursal fluid becomes contaminated
with microorganisms through the pinhole. Nevertheless, the
1 contamination presents no special problem as long as the
2
pinhole drains freely to the outside. Pinholes become infected
when the delicate balance between the patient’s natural
defenses and the bacteria’s infective capability changes. This
alteration can result from (1) the development of an abscess
(closed space) around the pin; (2) the presence of necrotic
tissue in the pinhole, which can become the focus of sepsis;
A B C D and (3) the presence of excessive motion between a pin and
adjacent tissues, which increases fluid production.
1
4
ABSCESS FORMATION
As noted earlier, the fluid formed around the pin by the
local tissues drains to the external surface and is contaminated
Fig. 8.8 To mark the zones, stretch a surgical towel between the with microorganisms in the process. The amount of fluid
proximal and distal landmarks described in the text and mark the may be limited, especially when there is no motion between
position of the landmarks on the towel with a surgical pen. Fold the soft tissues and the implant, such as over the anterior
the towel so that the marks touch each other and mark the midpoint
tibia. The fluid dries on the surface, forming a crust. If this
of the fold. Lay the towel against the limb again and mark the midpoint
on the limb using the towel as a guide. In this manner, the limb section
crust restricts free drainage of the contaminated bursal fluid
will be divided in half. Repeat the procedure and find the midpoint of by sealing the pinhole, deep abscess formation may result.
each half, thus dividing the limb segment into four equal zones. Thus frequent pin care directed toward removal of the crust
from the pin–skin interface reduces pin sepsis.
SKIN NECROSIS
must be considered schematic, rather than representational Necrosis of the skin will occur if the tension (or compression)
(Figs. 8.9–8.27). produced by the pin interferes with the circulation of the
local subdermal capillary plexus. Plastic surgeons are mindful
of this principle when transposing skin flaps; trauma surgeons
PIN TRACT INFECTION using transcutaneous pins for external skeletal fixation must
also keep it in mind. Skin tension can occur immediately
Pin tract infection has always been the principal drawback after implant insertion or whenever a change in alignment
to the use of external fixation. Unfortunately, preliminary or length is made. Skin can also be pinched between pins
communications announcing the development of new fixators or wires if they are too close together.
rarely take note of this complication. Subsequent reports of
external fixator applications, however, provide evidence that HEAT INJURY
pin tract infections continue to plague these devices.48–52 Thermal damage to skin and soft tissues occurs when a
One problem in determining the overall incidence of pin high-speed drill bit becomes hot while passing through hard
tract infections is that different authors use different sets of cortical bone, burning tissue as it emerges from the opposite
criteria to define pin tract infection. This variance is present side of a bone. Avoid heat buildup by using a stop/start
even within a single institution, making a review of patients’ Text continued on p. 235
Thigh, Zone A
1st perforating a. & v.
Tuberosity of ischium
Lateral femoral circumflex a.

Femoral n. & branches
Superficial femoral a. & v.
Deep femoral a. & v.

Br. of post. obturator n.
Inferior gluteal a. & v.
Post. femoral cutaneous n.
Sciatic n. Greater saphenous v.
Lat. femoral
cutaneous n.
Br. of obturator n.
Fig. 8.9 Thigh Zone A. Anatomic Considerations.

1. The femoral shaft is quite lateral in the proximal thigh.
2. The sciatic nerve remains posteromedial to the femur throughout zone A.
3. The deep femoral artery comes to lie medial to the femur in the lower end of zone A, separated from it by the origin of the vastus medialis
muscle, but only one-half bone width away.
4. The lateral femoral cutaneous nerve is in line with the lateral cortex of the femur.
5. The lateral femoral circumflex artery winds around the lateral cortex of the femur at the base of the greater trochanter.
Pin Placement
1. Half-pin insertion from the 90-degree lateral position can be done with caution in the upper two-thirds of zone A, and with extreme caution
in lower zone A.
2. With care and image intensification control, additional pin insertion can be obtained throughout a wide range in the upper portion of this
zone.
a., Artery; br., branch; lat., lateral; n., nerve; post., posterior; v., vein.
Thigh, Zone B
Greater saphenous v.

Saphenous n.
Femoral n. cutaneous br.
Lat. femoral Greater saphenous v.

cutaneous n.

Sciatic n.
Post. femoral
cutaneous n.
Fig. 8.10 Thigh Zone B. Anatomic Considerations.

1. The femur is laterally placed throughout zone B.
2. The sciatic nerve is posteromedial to the femur, separated by one bone diameter.
3. The superficial femoral artery crosses the coronal plane of the femur between zone B and zone C.
4. The deep femoral artery and vein are medial to the femur in proximal zone B and posterior to the femur in distal zone B.
5. The lateral femoral cutaneous nerve is anterior to the femur.
Pin Placement
1. Extreme caution is necessary in proximal zone B with 30-degree medial placement, because the superficial and deep femoral vessels are
in a straight line and can both be injured with a pin or wire placed too far medially.
2. Additional half-pins may be placed in other directions, but keep in mind the intimate association of the deep femoral vessels to the shaft of
the femur.
Thigh, Zone C

Third perforating a. & v.

Saphenous n.
Sciatic n.
Fig. 8.11 Thigh Zone C. Anatomic Considerations.

1. The femur is more centrally placed on cross section, although anteriorly situated.
2. The sciatic nerve passes from medial to lateral behind the femur, approximately one bone width away.
3. The superficial femoral artery passes the coronal plane of the femur in zone C and is posterior to the bone at the lower end of this zone.
4. The deep femoral artery and vein are adjacent to the posterior surface of the femur, but terminate at the lower end of zone C.
Pin Placement
1. Wires, full pins, or half-pins can be inserted from the 60-degree medial or 120-degree lateral position.
2. Half-pins can be cautiously inserted from the 0-degree anterior position in distal zone C because the deep femoral artery and vein are no
longer present (not shown).
3. Wires, full pins, or half-pins can also be inserted 90 degrees medial or 90 degrees lateral in distal zone C.
a., Artery; n., nerve; post., posterior; v., vein.
Thigh, Zone D
Popliteal a.
Popliteal v.
Saphenous n.
Tibial n.
Common peroneal n.
Lat. sural cutaneous n.
Fig. 8.12 Thigh Zone D. Anatomic Considerations.

1. The femur is an anterior structure until the flair of the condyles.
2. The sciatic nerve is posterior to the femur in proximal zone D crossing to the lateral side while dividing into the tibial and peroneal
divisions.
3. The femoral artery becomes the popliteal artery and, with the popliteal vein, is immediately posterior to the femur in zone D.
4. The synovial cavity of the knee joint enlarges to encompass the anterior half of the femur immediately above the joint line.
Pin Placement
1. Wires, full pins, or half-pins from 90 degrees medial or 90 degrees lateral are safe.
2. Half-pins from the 90-degree lateral position have the additional advantage of not transfixing the vastus medialis muscle.
3. At the level of the epicondyles, the synovial cavity is present anteriorly and posteriorly, leaving only 1 inch of extrasynovial bone. Three or
four pins may be placed close to each other in a transverse plane through the bone at this level, although if four pins are placed, the most
posterior pin may pass through the synovial cavity.
Leg, Zone A
Lateral sural cutaneous n.
Saphenous n.
Deep peroneal n.
Superficial peroneal n. Greater saphenous v.
Tibial n.
Medial sural cutaneous n.
Lesser saphenous v.
Anterior tibial v. & a.
Peroneal a. & v.
Posterior tibial a. & v.
Fig. 8.13 Leg, Zone A. Anatomic Considerations.

1. The shape of the tibia changes rapidly through this zone.
2. The popliteal artery is posterior to the tibia where it divides into its terminal branches.
3. The superficial and deep peroneal nerves are lateral to the fibula as they wind around the fibular neck.
4. The saphenous nerve and greater saphenous vein are posterior to the tibia on the medial side of the limb.
5. In distal zone A, the anterior tibial artery is on the anterior surface of the interosseous membrane and the peroneal and posterior tibial arteries
are posterior to the tibia, accompanied by their associated veins.
Pin Placement
1. Wires and full pins (or half-pins) can be placed in the 90-degree medial to 90-degree lateral direction throughout zone A.
2. Pins can be placed parallel to the joint line (and to each other) through the condyles of the tibia in proximal zone A.
a., Artery; n., nerve; v., vein.
Leg, Zone B
Saphenous n.
Deep peroneal n.
Anterior tibial v. and a.
Superficial peroneal n.
Tibial n.
Fibula
Medial & lateral
sural cutaneous n.
Lesser saphenous v.
Peroneal
a. & v.
Fig. 8.14 Leg, Zone B. Anatomic Considerations

1. The tibia has a triangular cross section throughout zone B, with the lateral surface relatively vertical, and the medial surface oblique.
2. The posterior tibial vessels, the tibial nerve, and the peroneal vessels maintain a constant relationship throughout zone B with respect to
the posterior surface of the tibia and the medial surface of the fibula.
3. The anterior tibial artery and vein and the deep peroneal nerve lie on the anterior surface of the interosseous membrane in zone B, traversing
from the anterior ridge of the fibula toward the lateral ridge of the tibia.
Pin Placement
1. Wires, full pins, or half-pins can be inserted from 90 degrees lateral or 90 degrees medial.
2. Half-pins can be inserted with caution from the 30-degree medial (or 45-degree medial) position perpendicular to the oblique medial surface
of the tibia. The tip of the pin will penetrate the tibialis posterior muscle. Bear in mind the relationship of the peroneal artery and vein,
adjacent to the medial corner of the fibula.
Leg, Zone C
Superficial peroneal n. Greater saphenous v.

Saphenous n.
Deep peroneal n.
Anterior tibial v. & a. Posterior tibial a. & v.
Tibial n.
Peroneal a. & v.
Sural n.
Lesser saphenous v.
Fig. 8.15 Leg, Zone C. Anatomic Considerations.

1. The tibia retains its distinctive triangular cross section.
2. The posterior tibial artery and vein and the tibial nerve remain posterior to the tibia and the peroneal vessels remain slightly medial to the
fibula.
3. The anterior tibial artery and vein and the deep peroneal nerve have completed their traverse of interosseous membrane and are adjacent
to the posterolateral corner of the tibia throughout zone C. These structures begin to traverse the lateral surface of the tibia in distal zone
C.
4. The saphenous nerve and greater saphenous vein are located at the posteromedial corner of the tibia in the subcutaneous tissue.
Pin Placement
1. In the upper part of zone C, wires, full pins, or half-pins can be safely placed from the 90-degree medial or 90-degree lateral direction.
2. Half-pins are difficult to place into the oblique medial surface of the tibia in zone C, because of the intimate relationship of the anterior tibial
vessels to the bone. A 0-degree half-pin would be safe in distal zone C, but it is technically difficult to place because of the obliquity and
thickness of the bone.
3. In distal zone C, pin placement from the 90-degree lateral or 90-degree medial position can endanger the anterior tibial artery and deep
peroneal nerve.
Leg, Zone D
Anterior tibial
v. & a.
Peroneal
a. & v.
Deep peroneal n.
Dorsal medial Tibial n.

cutaneous n.

Dorsal intermediate
cutaneous n.
Lesser saphenous v.
Sural n.
Achilles tendon
Fig. 8.16 Leg, Zone D. Anatomic Considerations.

1. The posterior tibial artery and vein and the tibial nerve remain posterior to the tibia, traversing medially as they approach the ankle joint.
2. The anterior tibial artery and vein, and the deep peroneal nerve, are on the lateral surface of the tibia in proximal zone D. They lie on the
anterior surface of the tibia in distal zone D.
3. The saphenous nerve and greater saphenous vein are on the medial side of the tibia throughout zone D.
4. The superficial peroneal nerve has divided into its terminal branches in this zone.
Pin Placement
1. Half-pins can be placed from the 30-degree medial position into the subcutaneous portion of the tibia.
2. Wire, or full-pin, placement from the 90-degree medial and 90-degree lateral directions can be accomplished in the distal two-thirds of zone
D.
3. Wire, full pin, or half-pin placement from 90 degrees medial or 90 degrees lateral can endanger the anterior tibial artery and deep peroneal
nerve in the proximal one-third of zone D.
Foot
1st dorsal metatarsal a.
Flexor hallucis
longus
Plantar
arch Abductor hallucis
Lat. plantar n.
Peroneus longus tendon

Common plantar digital n.
Fig. 8.17 Foot. Anatomic Considerations.
1. Cross section through the metatarsals demonstrates the curvature of the transverse metatarsal arch.
2. The dorsalis pedis artery is between the first and second metatarsal shafts.
3. The plantar arterial arch is crossing beneath the third metatarsal shaft at the level illustrated.
4. The flexor hallucis brevis tendon is adjacent to the lateral inferior surface of the first metatarsal shaft.
Pin Placement
1. A wire, full pin, or half-pin can be inserted from the 90-degree medial position into the first metatarsal shaft. It will penetrate one or perhaps
two other metatarsal shafts but cannot transfix all of them.
2. A 45-degree medial half-pin can be inserted into the first metatarsal.
3. Other half-pin positions can be safely used into the metatarsal bones, including a 90-degree lateral pin into the fifth metatarsal shaft (not
shown).
a., Artery; lat., lateral; n., nerve.
Biceps tendon Arm, Zone A
Coracoid process
Scapula
Suprascapular n.
transverse Musculocutaneous n.
scapular a. & v.
Median n.
Post. humeral circumflex a.

Axillary a.
Humerus Ulnar n.
Radial n.
Axillary n.
Ant. humeral circumflex a.
Cephalic v.
Post. humeral circumflex a. & v.
Circumflex
scapular a. & v.
Fig. 8.18 Arm, Zone A. Anatomic Considerations.

1. The humeral head is largely intrasynovial, being surrounded by a joint cavity medially and posteriorly and by the subacromial bursa
anteriorly.
2. The main neurovascular bundle containing the brachial plexus is medial to the humerus, separated from it by a distance equal to the width
of the bone.
3. The anterior and posterior humeral circumflex vessels surround the upper humerus slightly below the surgical neck, accompanied by the
axillary nerve.
Pin Placement
1. Half-pins may be cautiously placed in the 90-degreee lateral position.
2. Half-pins can be inserted into the humeral head from 0 degrees anterior around laterally to the 90-degree lateral position, if the tip of the
pin does not penetrate the opposite cortex of the humeral head.
3. Below the level of the surgical neck of the humerus, pin placement may endanger the humeral circumflex vessels and the axillary nerve.
4. Below the anatomic neck of the humerus, half-pins can be placed from the 90-degree lateral position (not shown).
a., Artery; ant., anterior; n., nerve; post., posterior; v., vein.
Arm, Zone B
Radial n.
Musculocutaneous n.
Median n.
Brachial a. & v.
Cephalic v.
Basilic v.
Ulnar n.
Deep brachial a.
Med. brachial cutaneous n.
Radial n.
Medial head
of triceps
Radial n.
Fig. 8.19 Arm, Zone B. Anatomic Considerations.
1. The brachial artery and veins and the brachial plexus remain medial to the humerus in this zone.
2. The radial nerve separates from the main neurovascular bundle and passes posterior to the humerus in zone B, separated from the bone
by the medial head of the triceps.
3. The musculocutaneous nerve and cephalic vein are anterior to the humerus in zone B.
Pin Placement
1. Half-pins from 90 degrees lateral must be accomplished with caution in midzone B because of the position of the radial nerve medial to the
humerus.
a., Artery; med., medial; n., nerve; v., vein.
Arm, Zone C
Lat. cutaneous n. of forearm
Radial n. Brachial a. & v.

Median n.
Basilic v.
Ulnar n.
Superficial ulnar collateral a.
Radial n.
Radial collateral a. Lat. cutaneous n. of forearm

Medial cutaneous n.
of forearm
Cephalic v. Ulnar n.
Radial n.
Fig. 8.20 Arm, Zone C. Anatomic Considerations.

1. The radial nerve winds around the lateral side of the shaft of the humerus in contact with the bone.
2. The brachial artery, veins, and branches of the brachial plexus remain medial to the humeral shaft. The ulnar nerve separates from the main
neurovascular bundle in this zone.
3. The musculocutaneous nerve becomes the lateral cutaneous nerve of the forearm and remains anterior to the humerus.
Pin Placement
1. Half-pins should only be placed in the 90-degree lateral position in the humerus with direct observation of the radial nerve through a surgical
exposure.
a., Artery; lat., lateral; n., nerve; v., vein.
Arm, Zone D
Ulnar n.
Radial n. Brachial a. & v.
Median n.
Cephalic v.
Basilic v.
Lat. cutaneous n.
of forearm
Ulnar n.
Radial n.
Medial cutaneous n. of forearm
Dorsal cutaneous n. of forearm
Radial n.
Ulnar n.
Fig. 8.21 Arm, Zone D. Anatomic Considerations.

1. The distal humerus flattens and is rotated with the lateral epicondyle 30 degrees posterior to the medial epicondyle.
2. The radial nerve lies on the lateral side of the radius in proximal zone D but is anterior to it in the distal portion of the zone.
3. The median nerve remains anterior and medial to the bone throughout this zone.
4. The ulnar nerve passes posterior to the plane of the distal humerus and lies in contact with the posteromedial corner of the bone immediately
above the elbow.
Pin Placement
1. Half-pins can be placed with caution from the 180-degree posterior position. The median nerve and brachial artery are separated from the
shaft of the humerus by the thickness of the brachialis muscle in zone D. Likewise, half-pins can be placed from the 150-degree medial
position.
2. Half-pins, full pins, or wires can be placed from the lateral epicondyle into the medial epicondyle. Unfortunately, the proximity of the ulnar
nerve to the medial epicondyle of the humerus makes pin placement in this position somewhat dangerous. It is recommended that the ulnar
nerve be exposed for transepicondylar wire or placement.
a., Artery; lat., lateral; n., nerve; v., vein.
Forearm, Zone A
Ulnar n.
Medial cutaneous n. of forearm

Dorsal. cutaneous n. of forearm
Ulnar a. & v.
Radial n.
superficial br.
Median n.
Basilic v.
Ulnar n.
Radial n. deep br.
Radial a. & v.
Common interosseous
a. & v.
Median n.
Ulnar a. & v.
Radius
Ulna
Fig. 8.22 Forearm, Zone A. Anatomic Considerations.

1. The deep branch of the radial nerve winds around the lateral side of the humerus within the substance of the supinator muscle.
2. The brachial artery divides into its terminal branches (the common interosseous artery and the ulnar artery) in zone A; they are anterior to
the proximal ulna in distally.
Pin Placement
1. Half-pins can be inserted into the proximal ulna from the 150-degree medial direction. Image intensification fluoroscopy is recommended.
Cross-wires can be placed in the proximal ulna posterior to the ulnar nerve.
2. Pin placement into the proximal radius is dangerous because of the location of the deep branch of the radial nerve. If it is necessary to
stabilize the proximal radius with external fixation, it is wise to identify this structure surgically before pin insertion.
3. In distal zone A, pins may be placed into the ulna from the 150-degree lateral position (not shown).
a., Artery; br., branch; n., nerve; v., vein.
Forearm, Zone B
Ant. interosseous a. & n.
Cephalic v.
Med. cutaneous n. of forearm
Median n.
Ulnar a.
Ulnar n.
Basilic v.
Lat. cutaneous n. forearm Radial n. & a.
Radius Ulna
Post. interosseous a. & n.
Fig. 8.23 Forearm, Zone B. Anatomic Considerations.

1. The radial, ulnar, and median nerves remain in relatively constant position throughout zone B.
2. The anterior interosseous artery and nerve lie on the anterior surface of the interosseous membrane.
3. The deep branch of the radial nerve lies adjacent to the posterior interosseous artery, posterior to the interosseous membrane and separated
from it by muscle.
Pin Placement
1. Half-pins can be inserted into the ulna from the 150-degree medial position. Depth can be assessed with fluoroscopy.
2. Half-pins can be inserted (employing considerable caution) into the radius via the 60-degree lateral position. As with half-pin insertion into
the ulna, fluoroscopy control is recommended.
a., Artery; ant., anterior; lat., lateral; med., medial; n., nerve; post., posterior; v., vein.
Forearm, Zone C
Ulna
Median n.
Ant. interosseous n. & a.
Ulnar n.
Radius Ulnar a.
Basilic v.
Post. interosseous a.
Radial a.
Cephalic v.
Radial n.
Ext. carp. rad. longus
Fig. 8.24 Forearm, Zone C. Anatomic Considerations

1. The superficial branch of the radial nerve and radial artery are anterior to the radius in zone C, becoming more lateral and superficial in the
distal part of this zone.
2. The median nerve remains in the middle of the forearm, surrounded by muscle.
3. The ulnar nerve and ulnar artery remain anteromedial to the ulna throughout zone C.
Pin Placement
1. Half-pins may be placed into the ulna with caution from the 150-degree medial direction. In fact, half-pins may be inserted into the ulna
from the 180-degree posterior position and the 150-degree lateral position as well, being mindful of the position of the extensor tendon as
illustrated in distal zone C.
2. Half-pins may be placed into the radius from the 150-degree lateral position. Pins may also be placed into the radius from the 180-degree
posterior position if care is taken to avoid impalement of extensor tendons.
a., Artery; ant., anterior; ext. carp. rad., extensor carpi radialis; lat., lateral; n., nerve; post., posterior; v., vein.
Forearm, Zone D
Radius
Ulna
Ulnar a.
Radial a. Ulnar n., volar br.
Ulnar n., dorsal br.
Basilic v.
Radial n.
Median n.
Radial n., volar br.
Radial n., dorsal br.
Cephalic v.
Fig. 8.25 Forearm, Zone D. Anatomic Considerations.

1. The radius and ulna are posteriorly located in the cross section of the forearm.
2. The radial nerve is lateral to the shaft of the radius, dividing into dorsal and volar branches in zone D.
3. The median nerve remains within the volar muscle mass.
4. The ulnar nerve divides into dorsal and volar branches, the dorsal branch passing to the posterior aspect of the distal forearm.
5. The extensor and flexor muscles become tendinous in zone D.
Pin Placement
1. Half-pins may be inserted with caution from the 150-degree medial direction into the ulna.
2. Half-pins may be placed into the distal radius from the 150-degree lateral direction. Note the relative position of the extensor tendons.
a., Artery; br., branch; n., nerve; v., vein.
Hand
Median n.
Ulnar a., superficial br.
Flexor pollicis Ulnar n., superficial br.

longus
Ulnar n., deep br.
Ulnar a., deep volar br.
1st volar
metacarpal a.
Deep volar arterial br.
Fig. 8.26 Hand. Anatomic Considerations.

1. Cross section through the metacarpal shafts demonstrates the close relationship of the radialis indicis artery to the volar surface of the
second metacarpal.
2. The palmar metacarpal artery to the second web space is adjacent to the radial volar surface of the third metacarpal shaft.
3. The ulnar artery and deep branch of the ulnar nerve are volar to the fourth metacarpal shaft, separated from it by muscle, a distance equal
to the width of the bone.
Pin Placement
1. Wire, full-pin, or half-pin placement from the 90-degree lateral position can be safely passed through the shafts of the second, third, and fourth
metacarpals. Extensor tendon impalement may occur as the pin passes through the skin on the medial side of the dorsum of the hand. The
oblique lateral surface of the second metacarpal makes pin insertion difficult because the tip of the pin tends to slide on the bone.
2. Half-pin insertion into the second metacarpal from the 150-degree lateral position can be safely accomplished if done carefully.
3. Half-pin placement into the fifth metacarpal shaft from the 120-degree medial position can be done with caution, although the curved surface
of the bone makes pin insertion difficult.
a., Artery; br., branch; n., nerve.
Pelvis
Fig. 8.27 Anatomic Considerations.

1. The ilium’s inner table is separated from the
abdominal contents by the iliacus muscle.
2. The iliac wings are concaved medially.
Pin Placement
1. Half-pins can be inserted along the iliac crest
aiming at either the sciatic notch or sacroiliac
joint from the 20-degree lateral position.
2. Full-pin placement from the anterior inferior
iliac spine to the posterior inferior iliac spine
requires a special alignment guide.
3. Pin placement is safer if the tip of the pin
penetrates the outer table of the ilium rather
than the inner table.
BONE NECROSIS
Necrosis of bone can occur with the heat generated from
drilling. Damage to osteocytes occurs after exposure to
temperatures of 55°C (131°F) for 1 minute or more. Indeed,
the mechanical properties of cortical bone change when
exposed to temperatures of 50°C (122°F) or more.53–55 The
best way to prevent heat buildup is to predrill bone holes
with a sharp drill bit, cooled with irrigation fluid, followed
by the hand insertion of the implant.
Because each pinhole provides a continuous portal of
entry for bacteria into the bone, heat-damaged bone is more
likely to become a focus of chronic infection than is normal
bone.
Excessive bone pressure—due to compression of a frame—
may cause necrosis of osseous tissue at the pin–bone interface.
The pressure reduces local bone circulation, resulting in
death of osteocytes; necrotic bone may become the focus of
a chronic infection.
MOTION
Relative motion between a pin and adjacent tissues contributes
to pinhole sepsis. As far as the microenvironment of the
Fig. 8.28 Irrigate the drill bit while drilling to cool it. pinhole is concerned, it makes little difference whether the
pin is moving with respect to the tissue or the tissue is sliding
back and forth along the pin. The effect is the same, which
is relative motion between soft tissue and a contaminated
foreign body (the pin). Reduction of motion at the pin–tissue
interface decreases the incidence of pin tract infections. (The
low incidence of pin tract infections in reported series of
fractures managed with pins-in-plaster is due, no doubt, to
skin immobilization by the plaster cast.)
The Pin–Skin Interface
Wherever possible, reduce motion between the pin and soft
tissues by selecting areas for pin insertion that avoid muscle
transfixion. Further reduction in soft tissue/implant motion
can be accomplished by wrapping the pins with a bulky wad
of gauze dressing between the skin and the fixator.
Recognizing that implant-site sepsis usually starts at the
pin–skin interface (rather than the pin–bone interface) has
led some researchers and clinicians to try to reduce the
Fig. 8.29 The bayonet point of an Ilizarov wire can twist soft tissue, infection rate associated with external fixation by coating
causing necrosis. the shaft of pins and wires with a known bacterial inhibitor,
specifically, silver or tobramycin.56–60
Silver-based antiseptics are being employed in everything
from neonatal eye drops to burn ointments. Although initial
drilling rhythm and irrigating the drill sleeve while drilling experimental studies suggested that silver coating of pins
(Fig. 8.28). could reduce infections in vitro60 and in a sheep iliac crest
model,57 a subsequent human trial revealed no difference
DEEP SOFT TISSUE NECROSIS in infection rate.56 Moreover, the presence of free silver in
Necrosis of deeper soft tissues develops when tissues are the serum of patients in the silver-coated pin group caused
compressed by an implant after it has been inserted. Such the researchers to terminate the study and recommend against
tension occurs in the anterior compartment of the lower leg the continued use of such implants, effectively eliminating
if a pin pushes the anterior compartment musculature further development with such devices.58
posteriorly. (It is far wiser to transfix the muscle by pushing The effectiveness of the antibiotic tobramycin against both
the pin straight in, thereby avoiding undue tension.) Necrosis staphylococci and gram-negative rods suggested that local
may also be produced if soft tissue “winds up” around a application of the medication might reduce pin-site sepsis
spinning implant or drill bit. (This can best be prevented for transcutaneous implants. Unfortunately, tobramycin cannot
by the use of a sleeve for both drilling and pin insertion.) be coated directly onto metallic pins with any predictable
Smooth wires will not likely wind up soft tissues, although a elution, so tobramycin-impregnated methylmethacrylate pin
spinning bayonet point might do so (Fig. 8.29). sleeves were developed59 employing the antibiotic-cement
combination used for total joint replacement or formed into extends for many centimeters around the pinhole (a common
beads for the treatment of osteomyelitis. As with silver coatings, phenomenon when stainless steel pins are employed) occurs
the tobramycin-acrylic sleeves failed to deliver the expected rarely, if at all, with titanium implants.
benefit. Indeed, it seemed to some clinicians that the infection The only drawback to the use of titanium pins (aside from
rate increased when tobramycin sleeves were used. A reason- their higher cost) is their reduced stiffness compared with
able explanation for this observation is that the tobramycin stainless steel pins. Although in some situations, such flexibility
is eluted from the surface of the pins for a very limited might be desirable, most surgeons prefer stiff fixator-pin-bone
amount of time, with antimicrobial levels surrounding tissue configurations, especially when bone fragments must be
dropping off rapidly a few days after implantation. Although moved by the fixator to correct deformities. For this reason,
the initial high concentration of tobramycin may sterilize a researchers and manufacturers searched for a way to retain
closed space such as a cavitary osteomyelitis or a joint replace- stainless steel’s stiffness yet reduce the likelihood of implant
ment, a pin sleeve, constantly exposed to fresh bacteria on loosening. The result was HA-coated threads of stainless steel
the skin surface, may function as a contaminated foreign pins.55,75,76
body perpetuating the infection once the antibiotic has HA, the mineral of bone, is applied via an expensive but
leached out of the cement. reliable ion-plasma coating technique to the surface of stain-
less steel pins to permit osteointegration of the patient’s
The Pin–Bone Interface bone with the implant to reduce loosening. In a 1997 prospec-
Pin loosening contributes to the development of pin tive randomized study using a sheep model,75 Italian research-
tract infections. Hyldahl et al.,61 Perren,62 and others51,63 ers found that local pin-site osseous rarefaction was significantly
studied the pathophysiology of loosening hardware within lower—and extraction torque significantly higher—when
bone. They noted that bone resorption and subsequent HA-coated pins were compared with uncoated pins. Five
implant loosening results from cyclic (rather than con- years later, German researchers conducted a similar project
stant) pressure at the bone–metal interface. Once a pin with human patients, comparing titanium pins with HA-coated
becomes loose, pin–tissue interface motion will promote pins.76 They found a fourfold difference in extraction torque
sepsis in a manner consistent with mechanisms already in the coated-pin group and a marked reduction in pin-site
described.51 sepsis as well.
Employing only threaded pins can decrease motion at the Conversely, Pizà and coworkers in Spain compared HA-
pin–bone interface. If properly inserted, they will not slip coated pins to uncoated pins in a group of patients undergo-
back and forth in the bone as will smooth pins. Threaded ing limb elongation for stature increase.77 Although they
pins, especially tapered threaded pins, should not be “backed found a 20-fold decrease in pin loosening in the coated-pin
out” once they are inserted, as they tend to loosen more patients, the incidence of pin-site sepsis did not differ between
quickly thereafter. the two groups.
Another way to reduce cyclic pin motion is to increase Thus it appears that HA coating on pins, whether studied
the stability (stiffness) of the fixator configuration. Briggs in animals or humans, significantly reduces implant-site
and Chao64 and others65–71 determined that fixator stiffness loosening but may not decrease pin-site sepsis, except perhaps
can be increased by (1) increasing the number of pins; (2) in those situations where the infection is associated with
increasing the distance between the pins within each pin osteolysis and loose pins.
cluster; (3) applying pins closer to the fracture site; and (4) In our own clinical experience, the osteointegration associ-
incorporating pins that are mechanically stiff into the fixator. ated with either HA-coated steel pins or biologically inert
The problem of fixator stability becomes critical if one or titanium pins makes it almost impossible to remove threaded
more loose pins must be removed for sepsis. Loosening of external fixation pins from cortical bone in awake patients.
the remaining pins may occur as the overall stiffness of the Injecting local anesthetic into or around the pin site does
frame configuration decreases. These difficulties can be not help reduce the intolerable pain associated with trying
avoided in the first place if a sufficient number of pins are to break loose an osteointegrated pin; instead, general
inserted to allow removal of one or more pins without affecting anesthesia is used for fixator removal when bone ingrowth
the integrity of the fixation. As Naden stated, it is “better to pins have been used.
add a pin than to have one too few.”72 Clearly, modern technology has improved the longevity
Certain recent developments have helped reduce the inci- of external fixation with threaded implants, diminishing both
dence of pin tract infections caused by loosening, including late loosening and those infections associated with osteolysis
the use of titanium—rather than steel—pins, and hydroxy- and diminished fixation. However, as previously mentioned,
apatite (HA)–coated threads (usually applied to steel pins). early soft tissue pin- or wire-site sepsis has not responded
The use of pins made from a titanium alloy rather than favorably to antibiotic- or antiseptic-coated implants. Instead,
stainless steel results in a reduction in implant-site sepsis (as surgeons must resort to the time-honored methods of eliminat-
observed with other orthopaedic implant systems, including ing tissue necrosis at the time of pin or wire insertion, as
total joint implants and intramedullary nails).73 The toxic effect well as those techniques that stabilize the implant–skin
of steel on cellular function may be related to the elution of interface once the device is in place.
certain metallic ions—perhaps nickel or chromium—from
the implant’s surface. Titanium pins reduce the incidence STRATEGIES TO REDUCE IMPLANT-SITE SEPSIS
of pin tract infections by about 50%.74 Moreover, it has been
noted that when implant-site infections do occur around FIXATOR SELECTION
titanium pins, the problem stays localized to the immediate The selection of the appropriate fixator construct is particu-
environment around the implant. Extensive cellulitis that larly important. In general, the configuration should be quite
stiff. This feature alone will do much to prevent pin sepsis.51,77 When drilling, stop the drill every few seconds to allow
When dealing with a chronic bone infection or an extensively the cutting tip to cool. The heat generated by drilling not
contaminated wound, the fixation frame should be capable only damages the bone, but also “work-hardens” osseous
of extraordinary rigidity. If the orthopaedic problem is less tissue, which then resists further advancement. A worthwhile
complex and the application short term, a less rigid configura- practice is to irrigate the drill bit to cool it and conduct heat
tion will do. If planning a secondary surgery while the fixator away from the tip.
is in place, select a frame configuration with the contemplated If much resistance is encountered during drilling, check the
procedure in mind. If comminution of fracture fragments drill-bit tip between your fingertips for excessive temperature.
is present, the frame should permit control of intermediate If the tip cannot be comfortably held for 15 or 20 seconds, do
fragments. Because it is better to insert pins through intact not leave an implant in the bone hole, as there will be necrotic
skin, the fixator should permit pin placement to be dictated (thermally injured) bone in communication with the pin’s
by the nature of the injury rather than by the configuration bacteriologic environment—a setup for chronic osteomyelitis.
of the frame. Instead, insert the pin (wire) elsewhere. Likewise, the bone
in the drill bit’s flutes should be white, never black or brown,
PIN SELECTION which are signs of burnt bone (Fig. 8.30).
Smooth pins: Smooth pins should not be used for external
skeletal fixation. They create two holes in the bone but do PIN INSERTION
not offer the advantage of “screwed-in” bone fixation. The Use a manual handle for pin insertion, which should be
unfortunate experience with the Stader and Anderson devices accomplished through the drill sleeve. Avoid overinsertion.
in the 1940s was due, I believe, to insufficient fixation with
smooth pins. Inserting Transfixion Wires
Threaded pins: Both cylindrical and tapered-thread pins As with pins, avoid tissue necrosis when inserting wires, which
are available with or without the HA coating.63 Most knowl- can be caused by either wrapping up of tissues, excessive
edgeable surgeons prefer the coated pins, although there is tension, or thermal injury from heat buildup during drilling.
no clear consensus about which thread shape works best. With transfixion wires, a spinning bayonet point may wind
Some pins are both self-drilling and self-tapping, but such up soft tissues, causing necrosis. Therefore push transfixion
implants have fallen out of favor with most surgeons, who wires straight through the tissue to bone before turning on the
prefer to predrill each pin site. drill. If the wire misses the bone, withdraw it completely and
reinsert it rather than redirecting it within the limb’s tissues.
When inserting transfixion wires into bone with a power
PIN AND WIRE INSERTION CONSIDERATIONS
drill, the dense cortical bone, by offering substantial resistance
Fracture Alignment to the wire point’s progress, may cause heat buildup, which
Align the fracture as precisely as possible before pin insertion. hardens the bone even more, resisting additional progress
An unaligned fracture will create undue tension (a source of the wire point. For this reason, stop the drill every few
of possible necrosis) by the skin on the concave side of the seconds with a stop–start action to advance a wire slowly
fracture deformity when the fracture is reduced. The pins through hard osseous tissue
or wires may also pinch the skin on the convex side of the When inserting a transfixion wire with a motorized chuck,
fracture deformity, creating additional skin necrosis. Moreover, wire flexibility may, at times, cause the wire to bend, reducing
some fixators require precise alignment of rotation at the accuracy of placement. For this reason, whenever inserting
fracture site before pin insertion because the frame does a wire, manually grasp the wire close to its tip to stabilize it.
not permit correction of axial malalignment once the pins
are in place.
Predrilling
Inserting a self-drilling stainless steel pin into the tibia of a
young healthy adult male can be an exercise in frustration
for the surgeon. After drilling for a while and making no
headway, there is a tendency to push harder and turn the
drill faster. Heat (from drilling) increases the microhardness
of bone, making progress difficult.53 To make matters worse,
the cuttings (chaff) from the drilling of bone have no place
to go because the pin contains no fluting (groove). The
chaff also increases friction, making the drilling even more
difficult. Friction created by these factors increases the
temperature of the pinpoint until it is too hot to touch when
it emerges from the opposite side of the limb. It is easier
(and safer) if the surgeon predrills cortical bone through a
drill sleeve before pin insertion. A sharp drill bit will penetrate Fig. 8.30 Bone in the flutes of a drill bit should be creamy white in
bone more easily than will a pointed pin because the fluting color. Any brown or black spots on the bone’s surface indicate that
of the drill bit permits the chaff to be carried away from the the bone was burned during drilling. Such a bone hole should never
worksite, reducing friction and also the amount of effort be used for external pin or wire fixation, because the risk of osteomyelitis
required of the surgeon. is high.
Because a spinning wire can wrap up surgical gloves, hold • Penetrate muscles at their maximum functional
the wire with a wet gauze pad. length.
As soon as a transfixion wire’s point penetrates a bone’s
far cortex, do not continue drilling because the spinning This last rule—critically important for a successful long-term
wire tip might damage tissues on the limb’s opposite side. application—means that the position of a nearby joint must
Instead, grasp the wire with pliers and hit the pliers with a change as a pin or wire passes through the flexor and extensor
mallet to drive the wire through (Fig. 8.31). muscle groups. For example, when inserting a wire into the
A most important principle when using any transfixion lower leg, plantarflex the foot when transfixing the anterior
implant: If the tip of a wire (or pin) emerges from the opposite compartment, invert the foot when inserting wires into the
side of a limb either smoking, or too hot to be comfortably peroneal muscles, and dorsiflex the foot during triceps surae
held between the surgeon’s fingertips, the wire should be impalement.
withdrawn, cooled, and reinserted elsewhere.
FRAME ASSEMBLY
Implant–Skin Interface Management Frame assembly can be extremely time consuming if the
After inserting a wire or pin, but before attaching it to the surgeon is not familiar with the technical details necessary
frame, check the skin interface for evidence of tissue tension for constructing the proper spatial configuration of the fixator.
while the limb is in its most functional position—that is, with It is important to practice frame assembly before surgery. A
the knee extended, the ankle at neutral, and so forth. Interface piece of wood or synthetic bone can be used. Learn the
tension will create a ridge of skin on one side of a wire or correct names for the components, asking for them as one
pin. Incise the ridge to enlarge the skin hole around either would ask for any surgical instrument. The OR personnel
a transosseous pin or an olive wire. Close the enlarged hole will quickly learn the names of the components if they are
with a nylon suture (if necessary) on the side of the wire expected to hand them to the surgeon.
opposite the released ridge. Once the frame is assembled, skeletal alignment should
When the ridge of skin is adjacent to a smooth wire, be evaluated with roentgenograms or fluoroscopy. Some
slowly withdraw the wire (with pliers and a mallet) until
its tip drops below the skin surface. Allow the skin to shift
to a more neutral location and advance the wire again
until it passes through the skin in an improved position
(Fig. 8.32).
If the interface tension exists on the insertion side of
a limb, snap off the wire’s blunt end obliquely to create a
point and advance the wire to just below the skin surface
by the pliers–mallet method on the limb’s far side. Tap
the wire back through the skin after making a position
adjustment.
With either transfixion wires or pins, check the range of
motion to make sure that no undo tension occurs during
the anticipated movement required while the fixator is on
the limb. If necessary, an implant should be reinserted if
movement of an adjacent joint causes skin tension.
Certain important techniques of transfixion-wire inser-
tion ensure maximum functional limb use and joint
mobility:
Fig. 8.31 Use a mallet to drive a wire through soft tissues on the
• Avoid impalement of tendons. opposite side of the limb, thereby reducing the risk that a spinning
• Avoid (whenever possible) transfixing synovium. bayonet pit will damage soft tissues.
A B C
Fig. 8.32 (A) A wire can cause skin tension as it emerges (white arrow). (B) Withdrawing a wire causes skin tension and allows the skin to
shift to a more neutral position. (C) Push the wire forward through the skin in the new location with a mallet and pliers. The black arrow points
to the original wire position in the skin.
projections will be difficult to interpret because of the management consists of rest with elevation of the affected
presence of radiopaque components of the fixator. If this limb. The frequency of cleansing around the pinhole should
occurs, oblique projections can be obtained of both limbs be increased. I may enlarge the skin hole by infiltrating
(for purposes of comparison). If alignment is unsatisfactory, the skin around the pin with a local anesthetic, and then
the entire frame should be loosened and a manual correc- insert a size 11 blade into the skin adjacent to the pin. I
tion of the limb carried out. The frame should not be used also start the patient on oral antistaphylococcal antibiotics.
to correct malalignment of a fracture by compressing the If these measures fail to promptly relieve the problem, the
convex, and distracting the concave, side of the fracture pin clamp should be opened slightly and the pin checked
deformity. for loosening by wiggling it. If the pin is loose—or if the
maneuver produces pain—the pin should be removed. If
PIN CARE ROUTINE removal of the loose pin affects the stability of the fixator, a
As noted earlier, it makes little difference to the pinhole new pin must be inserted in another location. The pinhole
microflora whether the pin is moving in the soft tissues or should be curetted with a small curette after a septic pin is
the tissue is sliding along the pin; the effect is the same, removed. If, however, an infected pin is securely fastened
which is relative motion between the tissue and a contaminated to the bone, the patient should be admitted to the hospital
foreign body. Reduction of soft tissue motion around the for a brief course of parenteral antibiotics, bed rest, and a
pinhole can be accomplished by forming a bulky wad of deep incision and drainage of the soft tissues around the
gauze dressing wrapped around the pin to completely fill pinhole. Antibiotic therapy can be guided by cultures of the
the space between the skin and the fixator. This controls implant site. If the septic process is not resolved by these
sliding of the skin when the limb swells, after ambulation or actions, the involved pin should be removed and replaced
activity. with a new one in a different position. If the infection does
The question of daily pin care stirs much controversy among not involve the bone, drainage should stop in a few days.
workers in the field of external skeletal fixation. My routine If draining persists, there is a significant probability that
for pin care consists of daily cleansing of the pins and sur- the patient has developed a chronic implant-hole infec-
rounding skin with a soapy solution, using small swabs or tion, which will require curettage and perhaps even more
applicator sticks. If the patient is reasonably agile, he or she extensive care.
can wash around the pins with soap and water in the shower.
This is followed by application of an antibiotic ointment
(Neosporin or Bactroban), and then a bulky wrap—as FIXATOR-ASSOCIATED PROBLEMS
described earlier—to control the space between the skin and
the fixator. It is a rare individual indeed who happily wears an external
In spite of diligent efforts, however, some pins will become skeletal fixator. Patient-related problems caused by the frame
septic. Furthermore, pin tract infection, at times, seems to are pressure necrosis of the skin and undue or excessive
occur when least expected. A most carefully placed, thoroughly pain. Pin or wire breakage may occur while a fixator is in
released, and well-managed pinhole may become infected place, causing distress to the patient and his or her surgeon.
while others in the same patient do not. Nevertheless, close Disruption of the patient’s lifestyle and psychosocial problems
adherence to the principles outlined in this chapter will do associated with external skeletal fixation, generally related
much to control the factors primarily associated with pinhole to long-term application combined with protracted hospitaliza-
sepsis. tion, may occur.
Ambulatory Aids
PRESSURE NECROSIS
Because implant loosening is associated with sepsis, efforts
should be focused on reducing cyclic stresses at the implant– Continuous contact with the frame or one of its components
bone interface. Such stresses occur with unprotected weight will cause intense burning pain for several hours, followed
bearing in lower extremity applications. Therefore do not by ischemic necrosis of the tissues being compressed. This
permit patients to ambulate with a fixator in place without usually leads to an infection and a worsening of the fixator
supplementary ambulatory aids such as crutches (until the experience of all concerned.
bone consolidates). The reason for this is obvious. The The amount of clearance required between the skin
external fixator serves as an exterior skeleton when there is and the fixator varies from region to region. In the upper
no continuity of bone after a fracture. The mechanical stresses extremity, and in lower extremity applications where there
of weight bearing are transferred from the bone to the fixator is bone immediately under the subcutaneous tissues (as in
at the implant–bone interface. The implants, being flexible, the pretibial region of the leg), two fingerbreadths between
will transmit cyclic pressure associated with ambulation to the skin and the fixator are sufficient. Three or more finger-
the bone. This results in bone resorption and subsequent breadths are required over most soft tissue areas in the lower
implant loosening. For this reason, unprotected early weight extremity where there is muscle between subcutaneous tissue
bearing with an external skeletal fixator on the lower extremity and bone.
should be discouraged. If limb swelling is anticipated, additional clearance will
be necessary. Often more than three fingerbreadths are
DEALING WITH PINHOLE PROBLEMS required in the lateral aspect of the thigh in an obese
If the patient presents with evidence of pinhole sepsis after patient, because the soft tissues there bulge laterally when
application of an external skeletal fixator, the surgeon the patient is lying down. When applying an external fixator
should make every effort to resolve the problem. Initial to the pelvis, 10 to 15 cm clearance must be left for the
abdomen, so the patient can sit up. It is important to fill the require more narcotic medication for relief than do other
space between the skin and the fixator with a bulky gauze patients.
wrap, to prevent excessive motion between the skin and the Pain around implant sites after surgery, though significant,
implants. is usually overshadowed by the operative site symptoms.
However, if pain around an implant predominates among
the early postoperative complaints, inspect the site. Occasion-
BROKEN COMPONENTS
ally, pressure from these dressings against the skin can produce
Occasionally, pins break while the fixator is on a patient. discomfort, not unlike the pressure from a snug-fitting cast.
Chao and colleagues78 observed that static stresses on the The patient often complains of burning and can usually
pins of a fixator applied without compression are 70 times specify the implant causing the problem.
greater than the stresses on the pins of a fixator applied with Skin and soft tissue tension occurs with shifting of a mobile
compression because of the overall fixator stability made by tissue area impaled by transcutaneous implants. As with a
the bone being compressed. Thus compression of the fracture too tight bulky wrap, tension on the skin at the implant site
site should be achieved if at all possible. produces pain or a burning sensation.
DISRUPTION OF LIFESTYLE PAIN WHILE THE FIXATOR IS IN PLACE

When applying an external fixator, the surgeon should Ordinarily, the pain associated with a fixator diminishes
consider the logistical problems associated with wearing the to a tolerable level within 1 week after frame application.
frame. Cover the sharp ends of pins and wires with plastic However, it is not unusual for patients, including those
protectors. (Some manufacturers provide protectors with who are quite stoic, to describe a continuous dull ache
their fixation systems, but they are easy to fabricate from requiring codeine or a similar analgesic medication for
intravenous [IV] tubing.) control during the entire time the fixator is in place. In
Pins and wires should not interfere with the function of some individuals, these symptoms vary with activity levels,
the opposite limb. When applying a fixator to the upper being greatest when the patient is ambulatory and relieved
extremity, do not inhibit the arm from adducting to the side by rest.
of the body, if possible. In femoral applications, the frame When the patient is permitted to ambulate in the fixator
should not occupy the area medial to the upper thigh for without supplementary aids (such as crutches), the problem
reasons of personal hygiene and comfort. In general, fixators is worse. For this reason (and to prevent pin loosening),
should not be applied around the posterior thigh area, which supplementary ambulation aids are recommended whenever
would force the patient to lie prone for the entire time the a lower extremity fixator is applied. The aids should be
fixator frame is in place. continued until the fixator is removed.
Fixator frames have a tendency to loosen while they are Excessive or undue pain may develop during the time the
on the patient. At each clinic or office visit, check the patient’s fixator is in place. This symptom is most distressing to the
frame and tighten if necessary. Loosening tends to occur patient and should be investigated. At times, the patient
where the fixator components meet at right angles. Compres- may describe pain starting at a particular implant and
sion or distraction, if necessary, should be carried out in a radiating proximally or distally, suggesting nerve compres-
systematic fashion, that is, symmetric length adjustments done sion. The sensation may be continuous or intermittent and
at each visit. It is important to check for pin loosening, may be related to the position of the limb. Any pin that
especially if evidence of pin tract sepsis or pain is present produces significant radiating pain should be removed
when the patient is evaluated. because the involved pin may be putting pressure on a
sensitive nerve.
PAIN PAIN ON PIN REMOVAL

Pain after application of an external skeletal fixator is to be Patients who have had a very unpleasant pin removal
expected during the postoperative period and thereafter. experience seem to remember the event years later, even
The pain is usually well tolerated but excessive or undue when other aspects of the fixator application have long
pain requires evaluation and management. been forgotten. A general anesthetic is usually needed for
removal of a modern fixator that is securely integrated into
the bone.
POSTOPERATIVE PAIN
External fixation, like any surgical procedure, can be expected
PERSISTENT PAIN AFTER FIXATOR REMOVAL
to produce pain postoperatively. The pain is usually appropri-
ate to the nature of the problem for which the fixator was Pain after pin removal usually falls into one of the following
initially applied; for example, one can anticipate as much categories: (1) bone pain associated with bone hole sepsis;
postoperative pain from the application of a tibial external (2) neurogenic pain resulting from persistent nerve irritation;
fixator as would result from the use of internal fixation for and (3) pain associated with a healing fracture. Other causes
the same injury. The patient’s personality and pain tolerance of postfixator pain include the usual problems that occur in
threshold also determine the level of pain experienced and, the posttrauma period. These include joint pain associated
consequently, the quantity of analgesics necessary for pain with restriction of motion and malalignment of the joint
control. Patients with considerable drug experience seem to surfaces.
BONE PAIN PRINCIPLES UNIQUE TO THE

Persistent bone pain localized over the pinhole and lasting ILIZAROV METHOD
more than 3 or 4 days after an external fixator is removed
is unusual. If it does occur and is associated with persistent In acute traumatology, external fixator applications tend
inflammation or drainage, expect a chronic implant-site to be static: After application, the surgeon tightens the
infection to develop. Pain at the site can also occur after the device’s interconnecting hinges and the apparatus remains
hole has sealed over and the limb is quiescent. The patient unchanged until removal. Once Ilizarov discovered bone’s
may describe episodes of recurrent pain, sometimes accom- capacity to form new osseous tissue in a widening distraction
panied by redness and swelling, which may subside spontane- gap, however, the indications for external fixation expanded,
ously or after a brief course of oral antibiotics. However, if with limb lengthening and correction of deformities (both
left untreated, a pathologic fracture can occur through the congenital and acquired) now being routinely treated with
pin site as the cavity expands. fixator frames.15,80–85 To the familiar complications of external
fixation—implant-site sepsis, nerve and vessel injury, inhibi-
tion of function, failure to obtain union—were added an
NEUROGENIC PAIN
entirely new set of problems related to moving bone fragments
Chronic pain from nerve irritation should subside with the and regenerating bone formation. Moreover, the common
passage of time unless caused by limb lengthening or defor- complications of fixators tend to become more troublesome
mity correction. In such cases (which are rare in posttrauma when the apparatus is employed for limb lengthening because
reconstruction but fairly common in limb elongation for tension on the soft tissues at the implant–skin interface
congenital deformities), a release of a band of tissue compress- during elongation increases the likelihood of ischemia
ing the nerve may be necessary. and subsequent necrosis of dermal tissues, a setup for
infection.
A limb’s deep soft tissue structures—especially thick fascial
PAIN ASSOCIATED WITH FRACTURE HEALING
sheets, such as the interosseous membranes of the forearm
Pain associated with fracture healing localized to the site of and lower leg and the thigh’s linea aspera—resist stretching,
injury is similar to that seen with other modalities of treatment even when performed slowly over weeks or months. This, in
and usually subsides as the fracture consolidates. Solid union turn, can cause angulation of the lengthening bone segment
in a position of malalignment sometimes causes a dull ache or contractures of adjacent joints. If the contractures are
that lasts for many years. not addressed while elongation continues, the joints can
sublux or even dislocate completely.86 The author is aware
of cases of thigh lengthening for proximal focal femoral
PSYCHOLOGICAL PROBLEMS
deficiency, for example, where both the hip and knee dislo-
Many patients, toward the end of their treatment program, cated during treatment, a worrisome and difficult-to-correct
are anxious to have the fixator removed, even if no complica- combination.
tions or problems developed while the fixator was in place. Likewise, along with the typical difficulties encountered
Vidal found numerous socioeconomic and psychological while trying to obtain union of fractures treated with external
effects of long-term treatment in an external skeletal fixator— fixation, the creation of a long column of newly formed
including a sense of estrangement from their families, regenerate bone by the Ilizarov method presents a set of
concerns about their ability to make a living, and fear of problems unique to that tissue, including failure of ossifica-
amputation.79 These patients were plagued with anxieties tion, bending while in fixation, and fracture after fixator
and many had suicidal thoughts at one time or another. removal.
Alcohol and drug consumption increased while in fixation. Because posttrauma reconstruction usually involves
The incidence of these problems reflected the recently restoration of a limb to its original dimensions, one would
described posttraumatic stress disorders and depression expect fewer problems than might be encountered when
symptoms that often accompany severe trauma. However, lengthening a congenitally short limb because the injured
the prolonged nature of an external fixator application usually limb was, after all, once of normal length. This is not always
makes a bad situation worse. the case: Deep muscle trauma and secondary scarring results
Thus, viewed objectively, patients endure protracted in tissue as resistant to stretching as natural fascial bands, or
hospitalization, psychological duress, disruption of their even more so. Likewise, protracted unsuccessful trauma care
personal lives, and significant personality changes for the often leads to severe joint contractures before fixator applica-
preservation of a dysfunctional limb. Professional psychologi- tion. Indeed, the equipment may be used solely to overcome
cal counseling may help. posttrauma joint contractures. Needless to say, attempting
The surgeon has the responsibility to prepare the patient to restore limb length, even of only a few centimeters, in
for fixator application. It is worthwhile to tell the patient a limb that already has a stiff posttrauma equinus or knee
that pin tract infections are likely to occur. They should be contracture is a challenging ordeal for both the surgeon and
told that one or more pins will probably have to be changed the patient.
during the course of therapy, and that the procedure will Additionally, our capacity to create a column of new bone
probably require general anesthesia. These odds may be a of substantial length has enabled surgeons to rebuild limbs
bit higher than the actual likelihood of another anesthetic that otherwise would have been unsalvageable. The treatment
for pin management, but no harm is done by preparing the strategy in such cases usually involves intercalary bone
patient for the worst and hoping for the best. transport, a technique that includes internal bone elongation.
A B
Fig. 8.33 The Ilizarov method can be employed to elongate a shortened limb (A) or to overcome a skeletal defect (B).
The moving bone fragment must, of necessity, be secured oblique and often combined with malalignment of the bone
to a mobile component of the fixator, which slowly pulls the fragments in angulation, rotation, displacement (of the
fragment from its original position to its “docked” position mechanical axes), and shortening. When any or all of these
on the other side of the original gap (Fig. 8.33). In doing deformities are associated with a nonunion, circular external
so, the wires securing the fragment to the frame cut through fixation permits the surgeon to gradually correct all deformi-
the skin and deeper tissues by a process that involves tissue ties, either simultaneously or in succession. With simple
necrosis and sloughing along the implant’s path, with healing, angular displacements, a hinged fixator will prove sufficient
one hopes, on the trailing side. Thus in spite of advances in to solve the geometric problem, but for more complex
pin fixation attributable to HA coating, pin-site infections malalignment involving multiple planes, the Taylor Spatial
are still a problem, especially when bone fragments are in Frame, although rather expensive, has proven invaluable. A
motion. Therefore meticulous attention to the principle surgeon interested in employing this modality should attend
outlined earlier in this chapter is even more important for a workshop on its use because many parameters of the
fixator applications involving moving bone segments than deformity and frame configuration must be accurately
it is for frames applied for static purposes (see Fig. 8.33). determined and entered into a proprietary computer program,
Because this volume deals with trauma to the musculo- which produces a prescription for frame adjustment that the
skeletal system and its consequences, the following consid- patient uses to lengthen or shorten the frame’s struts.
erations apply to those situations in which bone fragments When an infection is present at the nonunion site, the
move with respect to one another, either for restitution of surgeon should thoroughly débride the infected bone—while
limb length and alignment or for filling in a defect created stabilizing the limb in an external fixator—thereby converting
by traumatic loss of osseous tissue. the problem of an infected nonunion to an uninfected
nonunion. Reconstruction of the limb after débridement
TREATMENT PRINCIPLES FOR NONUNIONS usually involves intercalary bone transport if the débridement
has resulted in any substantial loss of bone tissue and a
AND MALUNIONS
segmental skeletal defect.
One fundamental difference between treating a nonunion
and a healed malunion is that with a nonunion, the site of
SEGMENTAL SKELETAL DEFECTS
any deformity correction (if needed) has been predetermined
for the surgeon, as the correction must usually be made Segmental defects may be due to either bone loss at the time
through the nonunion site. of trauma, removal of nonviable fragments at initial débride-
If the nonunion is transverse (perpendicular to the bone’s ment, or the result of resection of a tumor or necrotic infected
longitudinal axis), compression with external (or internal) bone. When a segmental defect is present, any angulation,
fixation will stimulate union. Many nonunions, however, are rotation, translation, or combination of displacements can
easily be corrected through the soft tissues at the level of A transport ring and an attached pair of crossed wires or
the defect. For this reason, circular frames designed to deal pins is the most stable way to pull a bone fragment through
with segmental defects are usually rather simple; the configura- tissue. Unfortunately, the wires cut through the skin and soft
tion is tubular, with the connecting rods of the frame parallel tissues as the ring and its attached bone segment move
to each other and to the bone’s biomechanical axis. through the limb. At the end of bone transport, however,
A skeletal defect can be overcome by Ilizarov’s bone the crossed transport wires enhance compression at the point
transport method (Fig. 8.34). The bone ends must be matched of contact between the intermediate fragment and the target
to fit at final docking of the intercalary fragment with the fragment.
target fragment. The target site is often bone grafted to When oblique directional wires are used to move a bone
hasten healing. With very large defects, it may be possible segment through a limb, there is far less cutting of tissues,
to perform two corticotomies and move the resulting bone because the wires start out nearly parallel to the limb’s axis.
fragments toward each other. Unfortunately, such oblique wires often do not provide enough
To eliminate the defect, make a corticotomy through pressure at the end of bone transport to ensure stable
healthy bone at some distance from the defect; thereafter, interfragmentary compression between the intermediate
the intercalary segment between the defect and the corti- fragment and the target fragment. For this reason, a surgeon
cotomy is pulled through the tissues until the defect is closed using oblique directional wires must often insert a pair of
and new bone forms in the distraction zone. The fragments crossed wires (connected to a ring) into the intermediate
should be perfectly aligned with the longitudinal elements fragment at the end of bone transport to enhance compression
of the fixator. If this is not achieved, the transported fragment at the point of contact. In such a case, the patient would
will not meet up with the target fragment. require a second operation to insert the supplementary
If the defect is smaller than 1.5 cm, it is possible to compress compression wires.
the defect acutely (after appropriate débridement) and
lengthen the bone through a corticotomy elsewhere.
JOINT MOBILITY
It is unwise to acutely close a skeletal defect that is more
than 1.5 cm, as the redundant soft tissues surrounding the Intensive physiotherapy is also necessary to prevent the joint
defect tend to bulge out when the fragments are brought contractures and subluxations associated with limb elongation
together, creating an unsightly appearance to the leg and and the correction of deformities. Even if the fixator is applied
kinking of both lymphatic and venous drainage. As this redun- to deal with a fracture or a nonunion—conditions not
dant skin is trapped between the wires, it cannot contribute ordinarily associated with stretching of tissues—irritation of
to lengthening of the limb through another section of the muscles impaled by pins or wires can lead to restriction of
bone. Therefore the patient is left with a peculiar-looking joint mobility. Thus physical therapy has an important place
limb with bulky redundant tissues at one level and tight, in the management of all patients in external fixation.
stretched skin at another. With this problem in mind, when Whenever bone fragments are moved with respect to one
dealing with a segmental defect of more than 1.5 cm, it is another, soft tissues are placed under tension: the greater
better to leave the soft tissues at length, and eliminate the the movement, the greater the tension. For this reason, it is
defect by gradual transport of the intermediate segment. important for the surgeon to consider every Ilizarov fixator
A segment of bone can be pulled through a limb with (1) application that involves movement of bone fragments as a
a transport ring and cross wires or pins or (2) with oblique form of limb lengthening, even if the extremity does not
directional wires. end up longer as a result of the procedure.
A B C D
Fig. 8.34 Infected intramedullary nail treated with débridement and bone transport. (A) Initial presentation. (B) At surgery, after removal of
nail, débridement of nonviable bone and proximal corticotomy. (C) During bone transport. Note the widening distraction gap and the narrowing
defect. (D) Oblique view demonstration cancellous autograft to create a tibiofibular synostosis.
The important elements of every postoperative physical

REGENERATE HEALING AND MATURATION
therapy treatment plan designed to prevent deformities and
contractures include elastic splinting, passive stretching, active Frame stiffness may have to change throughout the course
use of the limb, and appropriate nighttime positioning. of treatment. Initially, a fixator must be rigid enough to hold
the fragments and the proper position, yet flexible enough
to allow axial dynamization during loading. Additionally, an
STRETCHING
overly stiff frame may cause osteoporosis between the proximal
Passive muscle stretching is another essential measure and distal mounting clusters as the frame bypasses the bone’s
designed to prevent contractures. The physical therapist must weight-bearing function. In the final stages of healing,
teach patients and family members how to stretch the calf, individual longitudinal elements can be loosened completely
the hamstrings, and other muscle groups. At least 2 or 3 or even removed. Likewise, individual pin- or wire-gripping
hours a day should be devoted to this activity, especially in clamps can be released in sequence permitting greater and
cases involving substantial lengthening. In fact, the greater greater load on the bone. Before removing the frame, it is
the anticipated elongation, the more time per day must be wise to allow the patient to walk around for a few days with
devoted to passive muscle stretching. the transosseous implants in place, but no load sharing by
Interestingly, active muscle exercises do not help much the fixator. Ilizarov calls this final period of consolidation
in preventing contractures. For example, active dorsiflexion “training the regenerate.”87
of the ankle is not nearly as effective as passive stretching of There is evidence that tardy regenerate ossification responds
the calf musculature in limiting equinus contractures. to certain physical stimuli, including ultrasound and elec-
tromagnetic stimulation, which speed maturation of the newly
forming bone.88–91 It is best to use such modalities after
CONTRACTURES
reaching the limb’s ultimate length or axis correction, lest
Contractures can occur, of course, whenever a fixator is premature ossification stop the process before reaching the
applied, especially if the movement of muscles and joints is goal. Bone grafting of the regenerated region is rarely neces-
inhibited, either by the implants, muscle impalement, or sary. Slow ossification can almost always be traced to limited
pain. The most serious contractures develop, however, when ambulation or inhibited functional use of the limb.
bone segments are moved with respect to one another— With bone transport procedures, the “docking site” where
especially during limb lengthening. Fortunately for the the moving intercalary fragment of bone meets the target
traumatologist, contractures associated with external fixation fragment, tardy bone healing frequently occurs. This happens
for the treatment of acute fracture, nonunions, or malunion because the advancing edge of the intercalary fragment
almost never proceed to subluxation or frank dislocation. becomes progressively dysvascular as it is pulled through the
When joint contractures do occur, however, they can prove tissues and away from its blood supply. In Russia, Ilizarov’s
quite stiff and resistant to correction by simple means (such group routinely freshens up the bone ends about 1 cm before
as Achilles tendon lengthening). docking by returning the patient to the OR for curettage of
bone ends about to make contact with each other. In the
United States surgeons will often preemptively apply a fresh
LIMB POSITIONING
autogenous bone graft to the docking site shortly after contact
Proper limb positioning during the night is one of the most between the bone ends is established (see Fig. 8.34D). This
important prophylactic measures available during limb may lead to a few too many grafting operations, as some
elongation or bone fragment movement. The 7 or 8 hours docking without grafting does result in union, especially if
a patient spends in bed may be the most important hours the spike of one fragment impales the medullary cavity of
of the day for a patient wearing an external fixator. During the other.
that time, joints allowed to fall into suboptimal positions Toward the end of treatment, test the limb manually. The
will resist correction during daylight. A lower extremity that bone should feel quite solid, resisting deflection in any plane.
is permitted to rest with the foot in equinus and the knee I usually have the patient test the stability of the limb by
flexed will likely develop a problem at both joints. A support standing on it. He or she should report no difference in the
behind the heel (rather than under the knee) forces the sense of stability, compared with having the frame secured.
knee into neutral position. Likewise, dynamic or static sup- I require the patient to walk around for a week with the pins
ports of the ankle should be used at all times during bone or wires and rings still connected to the limb, but with no
elongation. longitudinal connecting rods or struts in place. Most often,
patients prefer crutches for assisted ambulation during this
period of time.
FUNCTIONAL LIMB USE
Ambulation and upper extremity use not only promote
POST-ILIZAROV MANAGEMENT
ossification of the regenerate, but also help prevent con-
tractures, subluxations, and dislocations. Weight bearing, for After the frame is removed, it should not be necessary
example, serves as a means of passive calf muscle stretching to apply a splint, orthosis, or cast to the patient’s limb,
while maintaining tone and stimulating circulation in the although this is commonly done by surgeons who remove
limb. Eating, hair combing, gymnastics, dance therapy, and fixators before radiographic studies show solid cortical
other similar activities are also useful adjuncts to therapy. The bone on three sides of the regenerate. As Ilizarov once told
rhythmic movements involved with swimming, cycling, and me, “physiotherapy should be finished the day the fixator
walking are among the best therapeutic exercises available. comes off.”
By following the principles outlined in this chapter for both grafting is the hallmark of a well-thought-out treatment plan
Ilizarov and standard external skeletal fixator applications, a wherein the surgeon recognizes the worrisome nature of the
surgeon will reduce the incidence of problems that might lead fracture pattern at the time of injury and prepares to bone
to an unpleasant experience for both patient and practitioner. graft the limb within the first 6 to 8 weeks after the injury.
EXTERNAL FIXATORS AS EXTERNAL FIXATORS FOR DAMAGE

NONUNION MACHINES CONTROL ORTHOPAEDICS
External fixators have been condemned as nonunion machines An abundant body of trauma care literature has confirmed
because it seems that so many patients in trauma frames fail that certain strategies of initial management of severely injured
to heal their fractures (Fig. 8.35). There are several reasons extremities reduce the likelihood of serious complications,
for this observation: first, fixators are applied to the most while simultaneously enhancing the probability that the
severe fractures, those with a natural propensity toward patient’s functional outcome will be the best possible under
nonunion; second, with so-called spanning external fixators, the circumstances.92
weight bearing or functional use is either very difficult or One of these strategies involves early coverage of exposed
precluded altogether. And third, patients are transferred tissues, either by delayed primary closure if enough local
(often for insurance reasons) to surgeons not familiar with soft tissue is available or coverage with transposed or trans-
the original treatment plan leaving a patient in a sort of planted soft tissue flaps. Even though centuries of civilian
therapeutic limbo. and wartime experience have taught us the danger of primary
When applying an external fixator to an acute injury, closure over devitalized muscle, bone, and adjacent soft tissues,
reduction of bone fragments must be as accurate as with we have also learned that prolonged exposure of any type
internal plate fixation if the frame is to remain on the limb of tissue to the atmosphere invites microorganisms to move
during the entire treatment protocol. Suboptimal reduction in and establish long-term residence.93
might be acceptable with a temporizing fixator when the A second strategy involves delayed definitive repair of
surgeon plans to soon remove the device and employ internal displaced fractures, with the goal of restoring fragments to
fixation as the definitive form of stabilization. However, bear their original anatomic relationships without excessive
in mind that the best laid plans often go astray. Patients are devitalization caused by soft tissue dissection.94 Reduction
transferred after accidents to facilities where a new caregiver and internal fixation of fractures, regardless of how carefully
may not be comfortable with the plan of the first surgeon accomplished, causes reactive swelling of tissues. If such
and decides to continue the patient in the fixator. The engorgement is superimposed on the swelling caused by the
suboptimal alignment then becomes the basis for tardy healing original traumatic injury, wound closure without tension
or results in a malnonunion requiring a difficult reconstruc- becomes difficult; excessive traction of tight soft tissues
tion effort. It is far better to strive for optimal alignment frequently leads to incision breakdown, necrotic wound edges,
when the frame is first applied (unless circumstances preclude exposed hardware, bone, tendons, and soft tissues.
the time required to achieve this goal) and then deal with Waiting 7 to 14 days for swelling to diminish after a
any subsequent tardy union by bone grafting the troublesome traumatic injury before performing an open reduction and
region without the need for realignment. Indeed, early bone internal fixation has become a hallmark of thoughtful
musculoskeletal trauma management.95 Although the early
healing during the 1- or 2-week waiting period may make
reduction of cancellous fracture fragments a bit more chal-
lenging (compared with the ease with which fresh fracture
fragments can be pushed around), the trade-off yields sub-
stantial reductions in postsurgical wound dehiscence and
thus a lower risk of infection.37
Third, unstable fractures, especially those associated with
significant soft tissue damage, benefit from mechanical
stabilization as soon as possible after injury. As patients are
moved around acute care facilities, on and off radiograph,
computed tomography (CT), and magnetic resonance imaging
(MRI) tables, to and from the operating suite, and into and
out of the intensive care unit, jiggling of fracture fragments
is not only intensely painful, but also macerates and may
even kill marginally viable soft tissues and especially skin of
questionable vascularity. Likewise, blood clots are disturbed
by undue tissue motion, and bleeding may resume after too
much movement. Finally, delicate surgical repairs of vascular
A B injuries are easily torn apart when limbs flop around after
Fig. 8.35 Patient placed in external fixator spanning the region of surgery.
injury. (A) The frame was left in place for 6 months without further Fourth, surgeons often find it difficult to judge soft tissue
treatment. (B) Established nonunion with severe disuse osteopenia viability immediately after a catastrophic injury. At times,
and not a molecule of osteogenesis. tissues we thought were dead may truly be so, whereas in
other wounds, marginal soft tissue may survive unexpectedly. into the joint, or the joint itself may be severely damaged.
A “second look” return to the OR by patient and surgeon In either event, applying a temporizing external fixator
24 to 48 hours after an injury is often the best way to judge stabilizes the osseous and soft tissues, preventing further
the viability of tissue remaining in the wound.94,96,97 damage and reducing pain.
The goal of limb stabilization in this context permits return
trips to the OR for repeated débridement without disruptive
THE TEMPORARY FIXATOR
manipulation of fracture fragments, a potential source of
further soft tissue injury. When an external skeletal fixator is used as a temporizing
With these objectives in mind, the concept of temporary device, the frame configuration need not be as sturdy as
spanning external fixators has evolved.97 During fixator would be required for a more definitive application.96,98 As
application, precluding transcutaneous implants near the a general rule, patients who are so severely injured as to
region when subsequent internal fixation is planned eliminates require a temporizing external skeletal fixator as an early
the risk of pin- or wire-site sepsis contaminating the operative step in a protracted therapeutic strategy are rarely capable
field of the open reduction and internal fixation surgery of getting up out of bed and walking around with a fixator
(Fig. 8.36). in place on a lower extremity. Likewise, for upper extremity
When the zone of injury scheduled for definitive internal applications, such individuals will not soon be bowling or
fixation is limited to the middiaphyseal region of a long playing basketball.
bone, spanning external fixation can often be applied to the Under the circumstances, temporizing external fixators
same bone, with external fixation limited to the ends of that usually consist of two half-pins secured to bone proximally,
same bone. This would be the ideal situation because freedom and two more half-pins inserted distally, with one or more
of movement of the adjacent joints would not be inhibited longitudinal rods connecting the proximal pin group with the
during the period of temporary external fixation. Indeed, distal pin group. Typically, universal joint articulations connect
in such cases, it is also possible to convert a temporary external one rod to another when spanning a substantial distance.98
fixator to a more permanent one and dispense with internal Pin-gripping clamps, typically incorporating universal joints,
fixation altogether. completed the configuration. In many cases, one multihole
More commonly, however, joint involvement accompanies pin clamp is used for each pin cluster, although from a
injuries that lead surgeons to apply spanning external skeletal mechanical perspective, spreading out the pins in each
fixation: Either the fracture lines of the diaphysis extend fragment and securing each pin to its connecting rod with
its own pin-gripper creates a more stable mounting.96
Specific strategies for timing of frame application, initial
and subsequent wound débridement procedures, soft tissue
management, antibiotic prophylaxis, anticoagulation, and
other general principles of trauma care are covered in detail
elsewhere in this volume. Likewise, operative techniques for
the reduction in fixation of fractures and dislocations are
described in chapters organized by anatomic regions.
This section will emphasize concepts common to all fixator
applications used as part of damage control orthopaedics,
whereby the configuration should be mounted in a manner
that affords access to the wound for additional therapeutic
measures and, wherever possible, allows definitive fixation
without increasing the risk of deep sepsis caused by an earlier
pin-site infection.
MILITARY APPLICATIONS WHEN FLUOROSCOPY

IS NOT AVAILABLE
Military surgeons, as well as orthopaedic surgeons responding
to mass casualties related to natural disasters, may be forced
by circumstances to apply temporizing external skeletal
fixators in extremely austere environments without the benefit
of fluoroscopic control.99–102
In combat field situations, where fluoroscopy is not available
during damage control external fixator applications, we make
the following recommendations:
First, a hand drill (or hand brace) may be safely used for
predrilling when electric or pneumatically powered drills
are not available or practical. A hand drill improves the
tactile feedback as the far cortex is engaged, a measure that
Fig. 8.36 A spanning damage-control external skeletal fixation. Notice reduces overpenetration.
the medial subcutaneous pin insertion for the tibia and lateral pin Second, when possible, a drill sleeve (6 mm inner diameter)
placement for the femur. should be employed to prevent winding-up of deep soft tissues
by either the spinning drill bit or the pin during insertion. fixation for the femur, tibia, humerus, proximal ulna, and,
(Such tissue will be stripped of its blood supply and quickly when inserted obliquely, the distal radius as well.
become necrotic, a frequent cause of deep implant-site sepsis Fifth, although we recognize that a 50- to 60-mm thread
in the era before drill sleeves were part of the external fixator length half-pin is usually desired for large cancellous bone
application protocol.) Therefore we recommend that such ends, using two 30-mm thread length (nonparallel) half-pins
drill sleeves be put in the field kits. We realize that it requires in the distal femur or proximal or distal tibia/fibula, one
three hands to use a manual drill and simultaneously press from each side, connected across the front of the limb with
a drill sleeve to the bone. Hence, when working alone, the bars, creates a stable triangular construct, which can be
operator can dispense with the sleeve. connected via additional longitudinal bars to the diaphyseal
Third, we recommend restricting the drill-bit selection parts of the frame.
to one size: 6 mm diameter smooth shaft stepped down Additionally, there are other challenges unique to this
to 5 mm fluting diameter, 30 mm long. This will prevent setting. Patients injured during combat tend to have severe
overpenetration during drilling, which places neurovascular open wounds, and external fixator pins should be placed
structures close to the bone’s far cortex at risk. outside of these wounds whenever possible.
Fourth, we propose employing only 6 mm diameter half- The accompanying cross-section atlas includes information
pins with a 30-mm thread length for diaphyseal bone applica- about certain pin insertion sites and directions where half-pins
tion in the field. Such pins will not overpenetrate because can be inserted with low risk to nearby nerves, muscles, and
the end of the threads at the thread-shaft junction will prevent tendons. In the tibia, this is fairly straightforward, with pins
advancement in all but the most osteoporotic bone. In adults placed anteromedially along the face of the tibia being rela-
of combat age, a 30-mm thread length will provide bicortical tively safe (Fig. 8.37).
$ %
Fig. 8.37 (A) Safe zones for half-pin insertion into tibia (blue). (B) Surface anatomy demonstrating location of safe zones.
In the femur, anterolateral pin placement is ideal for knee without fluoroscopy should be done with an open approach,
spanning and is easier for litter evacuation than straight using anterior iliac crest pins, and pins placed with fingers
lateral pins (Fig. 8.38). or instruments defining the inner and outer tables of the
Calcaneal transfixion pins can also be placed safely, from pelvis.
lateral to medial to avoid the sural nerve branches, and
ensuring placement is posterior enough to avoid the medial
THE DRILL SLEEVE
plantar nerve branches (Fig. 8.39).
The upper extremity can typically be splinted in situations In noncombat situations, regardless of the availability or lack
where fluoroscopy is unavailable, and placing external fixation thereof of sophisticated OR equipment, whenever threaded
is normally not warranted. In the event temporizing external implants are used for external skeletal fixation, a drill sleeve
fixation is needed in field situations where fluoroscopy is should be employed for pin insertion. Ideally, predrilling
not available, the surgeon should avoid overpenetration of the bone hole with a sharp drill bit is desirable but not
the bone’s far cortex with either the drill bit or implant, and absolutely necessary if the implant itself has a cutting tip and
avoid inserting any transcutaneous implant in the lower half flutes to carry away the bone dust generated while the hole
of the upper arm where the radial nerve is in intimate contact is being made. Even in this situation, however, where no
with the humerus. high-speed drill bit is used, a drill sleeve is essential. Without
The pelvis similarly can be stabilized with binder or sheet a sleeve, drill bits and, to a somewhat lesser extent, threaded
application, and external fixation should be delayed until it pins wrap up soft tissues during insertion. This action strips
can be applied with fluoroscopic guidance. In the rare instance the tissues from their blood supply, creating necrotic material
where there will be a significant delay in moving the patient in the implant site, necessary pablum for microorganisms.
to higher level of care, or when severe open wounds preclude Indeed, the single measure that increased acceptance of
binder or sheet compression, pelvic external fixation applied external skeletal fixation by orthopaedic surgeons in the
$ %
Fig. 8.38 (A) Safe zones for half-pin insertion in the femur (blue). (B) Surface anatomy demonstrating location of safe zones.
CHOICE OF IMPLANTS
A substantial reduction in pin-site sepsis occurred when
titanium pins were introduced. Osseous integration at the
pin–bone interface reduced early implant loosening, a precur-
sor to pin-site sepsis. Likewise, coating a pin’s threads with
an osteoconductive substance, specifically calcium HA,
regardless of the metal, further diminished the incidence of
implant site sepsis.76,103–106
Each advance in the external fixation pin technology
appears to enhance the potential longevity of a fixator
application. However, every improvement seems to increase
the cost of the transcutaneous implants.
For temporizing external fixation, where device removal
is expected 2 or 3 weeks after mounting, costly transcutaneous
pins are not necessary, because the benefit of titanium pins
or coated pins does not become a critical factor in reducing
pin-site sepsis unless the frame has been on for several months.
A Therefore when applying a temporizing external skeletal
fixator, low-cost stainless steel pins will do.
REDUCING COSTS FROM INVENTORY CONTROL

A potential way of lowering the cost of a temporary external
skeletal fixator is to have only a limited number of implant
sizes available.
For adult applications, as one would expect in a military
field hospital, 6-mm-diameter pins are far more rigid, and
thus more stable, than 5-mm pins. Stiffness of the material
is proportional to the fourth power of diameter, so the extra
millimeter provided by thicker pins enhances the stability
of the overall configuration and reduces the need for more
than two transosseous implants per segment.
Likewise, a pin with a 30-mm thread length, when used
in an adult, can transverse the medullary canal and engage
B both cortices of the femur and tibia and even the calcaneus
with hardly any threads protruding from the far cortex.
Fig. 8.39 (A) Safe zone for insertion of pin into calcaneus. (B) Surface
anatomy demonstrating location of the safe zone.
IMPLANT DEPTH
For most upper extremity applications, especially those where
third quarter of the 20th century was the introduction of the fixator application is short term, 5-mm-diameter pins
the drill sleeve. Before that, septic pin sites were the hallmark are adequate, and a thread length of 20 mm will prove satisfac-
of external fixator applications. tory for virtually all upper extremity applications. In military
combat field situations, however, to reduce the inventory
CONVERSION TO PERMANENT needs, we recommend the use of the same half-pin size for
both lower and upper extremity applications (6-mm diameter;
EXTERNAL FIXATION
30-mm thread length). At this size, overpenetration of up
In some situations, primarily related to wound care logistics, to 10 mm is possible in the upper limb, so the surgeon should
a temporizing fixator is on a limb far longer than originally avoid depth plunging during drilling or pin insertion by
anticipated. In some cases, such a fixator may even be stopping progression once the opposite cortex of the bone
transformed into a definitive fracture care device. Although is engaged.
it is certainly possible to remove a temporary external fixator Modern external skeletal fixation pins are manufactured
and apply a more permanent configuration with new trans- from the bar stock. During the fabrication process, threads
cutaneous implants, it is more elegant to plan for such a are cut into the bar so that the exterior diameter of the
conversion in advance. threads is the same as the exterior diameter of the pin.
Often, experience with similar fracture patterns and soft (Typically, the core diameter of the threads is about 1 mm
tissue wounding allows a more experienced surgeon to smaller than the exterior diameter.) This feature precludes
recognize that definitive internal fixation may not be possible overinserting the pin because the implant will not advance
in a given situation. With this in mind, the location, number, in the bone once the threads have bottomed out. Ideally,
and material properties of the implants would certainly differ when a threaded pin is fully inserted, a few millimeters of
from those contemplated for short-term applications. the implant should stick out the far side of the bone because
the first two or three turns of the thread are of smaller vessel structures are at risk regardless of the method used
diameter than the rest (or incorporate cutting flutes) and to secure the frame to the bone. In several locations, a nerve
thus do not grip the bone very well, if at all. or vessel lies directly on the surface of a bone where it is
easily injured. In other instances, nerves or vessels traverse
USING THE ATLAS FOR DAMAGE CONTROL a limb perpendicular or oblique to its longitudinal axis,
making it vulnerable to injury. The following structures are
ORTHOPAEDICS
of particular importance in this regard.
The pin locations and the directions in the accompanying Deep to the femur, however, laying along its posteromedial
cross-sectional atlas have been selected to allow for safe pin side, is located the deep femoral artery, a structure that
insertion even if the threads protrude beyond the far cortex. provides transverse feeder vessels to the thigh muscles. More
Thus if a pin in the atlas is designated “safe” (indicated important, the superficial femoral artery, in the midthigh,
by blue color), it can usually be driven all the way through is one of bone diameter away from the femur in its coronal
the limb and out the opposite side without risk of nerve or plane. A surgeon inserting pins into the lateral cortex of the
vessel injury, provided that the location and direction are as femur should avoid overpenetration, a possible source of
indicated. true or false aneurysms, both of which have been created by
In the accompanying atlas, when a nerve, vessel, or tendon external fixation pins and wires. Limiting thread length to
is on the opposite side of the limb from pin insertion, but 25 or 30 mm should prevent damage to these structures, for
the distance exceeds one bone diameter, the level and direc- reasons explained earlier.
tion of insertion is designated “caution” (indicated by yellow
color). And if any nerve, muscle, or tendon on the opposite FEMUR
side of the limb from pin insertion is less than one bone The entire shaft of the femur is generally safe for pin insertion
diameter on the opposite side of the limb from insertion, from lateral to medial in the coronal plane of the body. The
the level and direction of implant insertion is designated lateral femoral cutaneous nerve, which traverses obliquely
“danger” (indicated by red color). from front to back in the upper lateral thigh, is easily pushed
When a direction of insertion is designated “safe,” a full out of the way when a trocar and sleeve is used for pin
pin can be used in place of a half-pin in such locations when insertion.
more stability and additional fixation are needed on the In the middle of the thigh, between zones B and C, the
opposite side of the extremity. Bear in mind, however, that superficial femoral artery crosses the coronal plane of the
when a threaded pin is driven through soft tissue without a limb one bone diameter medial to the femur. The deep
drill sleeve, wrapping up of soft tissues can cause significant femoral artery and veins lie adjacent to the posterior-medial
problems. Although drill sleeves are widely used in conjunc- corner of the femur in the lower part of zone B, but this has
tion with pin insertion on the near side of the limb, no such not been a clinical problem, perhaps because the vessels are
sleeves exist to protect soft tissues on the limb’s far side. To behind the coronal plane of the bone (Fig. 8.40).
overcome such concerns, special centrally threaded pins (with At times, surgeons insert pins into the femur in the anterior-
smooth shafts on both sides of the threads) were developed to-posterior direction, impaling the rectus femoris as they
in the 1970s. Unfortunately, they are rarely, if ever, used do so. Whereas the anterior-to-posterior direction is generally
nowadays, and may not be available except on special order. safe (because the sciatic nerve is more than one bone diameter
When external fixators are applied in damage control away from the femur), transfixing the rectus femoris eliminates
orthopaedics, full pins (through-and-through) are virtually knee flexion. Although this may be desirable in damage
never employed; half-pins serve well in virtually all anatomic control orthopaedics, especially when the distal femur or
locations.94,96–98 upper tibia is shattered, there is risk that the central part of
the quadriceps muscle will adhere to the bone if the fixator
DANGER REGIONS FOR PERCUTANEOUS PINS is left in place for too long. It often happens that a
INSERTED WITHOUT FLUOROSCOPY
As mentioned earlier, forward field hospitals in combat situ-
ations often lack fluoroscope capabilities, so military surgeons
were wondering about the safety of “blind” insertion into
lower extremities (i.e., half-pin insertion without the use of
fluoroscopy). Topp and colleagues,107 working at the Brooke
Army Medical Center, used cadaveric lower extremities to
assess the accuracy and safety of fixator application under
such trying circumstances. They concluded that if military
surgeons confined their pin insertion locations and directions
to certain safe corridors, the likelihood of significant nerve
or vessel injuries caused by the pins were within acceptable
limits, considering the nature of the casualties being treated.
Moreover, they learned that surgeons with greater experience
with external fixation were less likely to overpenetrate very Fig. 8.40 Half-pins can be safely inserted from front to back (taking
much past the far cortex during pin insertion.107 care not to overpenetrate past the bone) to most of the femur. However,
As a general principle, whether inserting external fixation quadriceps impalement is undesirable. Coronal plane pins can safely
pins or wires with or without fluoroscopy, certain nerve or be inserted in most regions of the thigh as shown in zone D here.
well-thought-out sequence of therapeutic interventions may about depth on the opposite side of the bone. In most loca-
be interrupted because the patient is transported to a different tions, a 30-mm thread length that cannot overpenetrate is
facility under the care of different doctors. Alternatively, quite safe. Throughout the lower leg, the neurovascular
problems pop up during treatment that make it necessary structures at risk are generally a bone diameter away from
for the surgeon to leave the external fixation device on the the far surface of the tibia. An even safer direction, except
limb for longer than originally anticipated. Weeks sometimes for one location, is to insert the pins in the coronal plane,
stretch into months. Patients lay around in extended-care something that can be accomplished from either the medial
facilities waiting for insurance issues or scheduling consid- or the lateral side of the bone (Fig. 8.41). Of course, inserting
erations, or some other delay in prompt conversion from pins on the lateral side of the bone in the coronal plane
external fixation to internal fixation, resulting in protracted means that the implants must cross the muscles of the anterior
time in the frame. compartment, thereby limiting ankle motion if this is desired.
The best way to prevent quadriceps binding to the front Inserting pins from the medial side, although perhaps a bit
of the femur is to apply pins, even those that are used more difficult because of interference with the opposite limb
temporarily, from the lateral side in the coronal plane or during the surgery, is remarkably safe. In fact, even if the
even aiming slightly anteriorly from slightly posteriorly (to pin passes through into the limb and sticks out from both
avoid impaling the deep femoral artery). sides, no neurovascular structures are likely to be injured,
Typically, applying the fixator from the lateral side of the with one exception. As mentioned earlier, at the junction of
femur and extending the configuration to the tibia means the third and fourth quarters of the tibia (zones C and D),
that some kind of articulation and intercalary bar must be the anterior tibial artery and deep peroneal nerve rest directly
used to get from the outer side of the femur to the inner on the lateral surface of the tibia and thus could be injured
side of the tibia. This is because most tibial mountings for by a coronal pin (Fig. 8.42).
damage control orthopaedics occur from the medial side of These neurovascular structures traverse obliquely from
the bone where the osseous surface is the subcutaneous. posterior to anterior and cannot easily slide out of the way
when a pin passes nearby because of their tight attachment
TIBIA to the bone. Fortunately, most of the innervation of the deep
The entire anterior-medial subcutaneous surface of the tibia
seems ideal for external fixation pin insertion, even without
the use of fluoroscopy. Having said that, the natural tendency
is to insert the pin perpendicular to the flat surface of the
tibia. This approach is generally safe if the surgeon is careful
Fig. 8.41 Half-pins or full pins can be inserted in the coronal plane
through most of the tibia except at the junction of the third and fourth
quarters (lower zone C and upper zone D) where the anterior tibial Fig. 8.42 As with the proximal tibia, full pins and half-pins can be
artery and deep peroneal nerve crosses the coronal plane of the tibia inserted in the coronal plane of the bone below the crossing point of
on the lateral surface of the bone. With control of depth, half-pins can the anterior tibial artery in deep peroneal nerve. Likewise, throughout
be inserted throughout the tibia perpendicular to the subcutaneous the tibia, half-pins can be inserted perpendicular to the medial sub-
surface. cutaneous surface.
peroneal nerve has already happened by the time the nerve

is so distal in the limb. However, loss of nerve function at
this level results in a patch of hypoesthesia in the dorsal web
space between the hallux and the second toe. Motor function
of the peroneal nerve controls the small extensor muscles
on the dorsum of the foot. The anterior tibial artery is one
of three vessels supplying the foot; it terminates as the dorsalis
pedis artery. Thus it is not critically important unless the
other two vessels (the posterior tibial artery and the peroneal
artery) have been damaged.
Pins inserted into the crest of the tibia directed from front
to back, though seemingly simple and safe, pose an unusual
risk: a ring sequestrum and osteomyelitis. The anterior tibial
cortices are particularly dense and thus can be overheated
during drilling, causing necrosis of the bone around the
pinhole, a sure setup for future infection.
HUMERUS
With respect to the humerus, the radial nerve is the primary
danger structure because of its intimate contact with first
the medial and then the posterior surface of the bone. This
occurs in the upper half of the upper arm (and zones A and
B). In the third quarter of the upper arm (zone C), the
radial nerve moves away from the bone but is, unfortunately, Fig. 8.43 Taking care not to overpenetrate, half-pins can be inserted
directly in the lateral position with respect to the humerus from posterior to anterior in the distal humerus.
and thus can be easily injured when the pin is screwed into
the bone from the lateral side. Fortunately, the nerve can
be palpated as a thick, oblique, ropey structure in the soft
tissues and thus pushed either forward or backward at the
time of insertion. Moreover, insertion is recommended in
this region with visualization of the nerve.
There are, however, safe locations in the humerus, although
they are not often recognized. Pins can be inserted from
front to back rather safely in the humeral head. Lateral to
medial insertion in this direction risks overpenetration and
the damage of the glenoid. This occurs because the bone is
cancellous in this region and thus there is no firm cortex to
stop the advancement of the pin, even one that is not threaded
beyond 30 or 40 mm.
The axillary nerve, which innervates the deltoid muscle,
sits on the deep surface of that structure, wrapping around
the upper end of the humerus about a hand’s breadth below
the lateral edge of the acromion process. Proximal to the
axillary nerve, the humeral head can serve as a fixation point Fig. 8.44 Half-pin insertion into the radius is risky without fluoroscopy
for the upper end of a temporizing fixator. Implants can be and precise control of depth and direction.
inserted from front to back, from lateral to medial, and even
from posterior to anterior. Bear in mind, however, that
overpenetration of a laterally placed implant will end up in skeletal fixation is usually applied in cases of severe limb
the glenoid surface of the scapula. trauma. Once the radius is fractured, the biceps muscle often
In the distal humerus, surprisingly, posterior to anterior spins the proximal fragment into supination while the remain-
insertion is reasonable. The brachial artery and median nerve ing portion of the bone follows the rotation of the palm and
are protected by the thickness of the brachialis muscle, which hand. This makes the exact position of the deep branch of
is at least as thick as the distal humerus (Fig. 8.43). However, the radial nerve difficult to ascertain (Fig. 8.44).
as the distal humerus approaches the olecranon fossa, the Distally, the superficial radial nerves can be easily injured
bone thins out considerably making fixation difficult. In this when inserting pins in this region. For this reason, a small
region, no more than a 20-mm thread length should be open incision with the section down to the bone will ensure
used. protection of these sensitive structures.
The radius becomes progressively more superficial in the
FOREARM distal forearm, where pins can easily be inserted into the
In the forearm, the radius is a dangerous bone for pin inser- bone, although it is wise to make a small incision and expose
tion because, like the humerus, the radial nerve wraps around the bone directly to best avoid damage to superficial branch
the proximal end. Damage control orthopaedics using external of the radial nerve.
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Principios de Fijacion Externa

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Principios de Fijacion Externa

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Principles and 8

8.1. The modular technique of applying external fixation.

Alternatively, implants are being developed that consist

may incorporate a compression-distraction apparatus in their

Throughout this chapter, frame configuration terminol-

is different from most other surgical procedures because the

are inserted into certain anatomic areas, such as the lateral

IMPLANT PLACEMENT TO AVOID

An atlas showing pin placement positions designed to reduce

charts an inaccurate procedure for determining the incidence

1st perforating a. & v.

Lateral femoral circumflex a.

Superficial femoral a. & v.

Deep femoral a. & v.

Inferior gluteal a. & v.

Post. femoral cutaneous n.

Sciatic n. Greater saphenous v.

Fig. 8.9 Thigh Zone A. Anatomic Considerations.

Superficial femoral a. & v.

Lat. femoral Greater saphenous v.

Deep femoral a. & v.

Fig. 8.10 Thigh Zone B. Anatomic Considerations.

Deep femoral a. & v.

Superficial femoral a. & v.

Post. femoral cutaneous n.

Fig. 8.11 Thigh Zone C. Anatomic Considerations.

Post. femoral cutaneous n.

Fig. 8.12 Thigh Zone D. Anatomic Considerations.

Lateral sural cutaneous n.

Posterior tibial a. & v.

Fig. 8.13 Leg, Zone A. Anatomic Considerations.

Fig. 8.14 Leg, Zone B. Anatomic Considerations

Superficial peroneal n. Greater saphenous v.

Fig. 8.15 Leg, Zone C. Anatomic Considerations.

Dorsal medial Tibial n.

Posterior tibial a. & v.

Fig. 8.16 Leg, Zone D. Anatomic Considerations.

1st dorsal metatarsal a.

Peroneus longus tendon

Biceps tendon Arm, Zone A

Post. humeral circumflex a.

Ant. humeral circumflex a.

Post. humeral circumflex a. & v.

Fig. 8.18 Arm, Zone A. Anatomic Considerations.

Med. brachial cutaneous n.

Lat. cutaneous n. of forearm

Radial n. Brachial a. & v.

Superficial ulnar collateral a.

Radial collateral a. Lat. cutaneous n. of forearm

Fig. 8.20 Arm, Zone C. Anatomic Considerations.

Radial n. Brachial a. & v.

Medial cutaneous n. of forearm

Dorsal cutaneous n. of forearm

Fig. 8.21 Arm, Zone D. Anatomic Considerations.

Medial cutaneous n. of forearm

Fig. 8.22 Forearm, Zone A. Anatomic Considerations.

Ant. interosseous a. & n.

Post. interosseous a. & n.

Fig. 8.23 Forearm, Zone B. Anatomic Considerations.

Ant. interosseous n. & a.

Fig. 8.24 Forearm, Zone C. Anatomic Considerations

Ulnar n., dorsal br.

Radial n., volar br.

Radial n., dorsal br.