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“External Fixator is a device uses for

stabilization and immobilization of long
bone open fractures.”

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History

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

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History

Keetley 1893, Ollier,

Roux

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 History

Parkhill 1894 Threaded

pins and clamp

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History

Lambotte 1902, self tapping threaded pins, rod,

adjustable clamps

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History
In 1917. Humphry is the 1st man who uses threaded pins,
but he uses only one pin above fracture and one below
the fracture site.

In 1948, Charnley popularized his compression device to

facilitate arthrodesis of joints.

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History

In 1966 and 1974,Anderson et al. uses transfixing pins

incorporated into a plaster cast for management of
large series of tibial shaft fractures .
From 1968 to 1970 Vidal and Vidal et al. modified
original Hoffmann device from a single half –pin unit to a
quadrilateral bicortical frame , greatly increasing rigidity.

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 Types
Type -1 Unilateral Uniplanar
Type -2 Uniplanar Bilateral.
Type -3
◦ Classical Bilateral Biplanar.
◦ Delta Unilateral Biplanar

According to Planes:
◦ Planner: Hoffman’s, orthofix etc.
◦ Circular: Ilizarov

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For periarticuler fracture
Thin wire and ring near joint 13

Schanz pin in shaft

 Intrinsic stability of frame (S)
EX I
S = -----------
L

E=modulus of elasticity =constant

I= moment of intertia= constant
L= distance of frame from axis.

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 Biomechanics

Thus Stability is inversely proportional to the distance of

the assembly from the bone

(closer the frame to bone -more stable assembly)

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To increase stability of bone –pin interface
1. Adequate no. of pins in each fragments
( 2 for most bone & 3 for femur)

2. Increase pin pitch (3.5mm) 16

3. Increase size of pin

Basic Components

A. Schanz Pin
4. 5mm short threaded for diaphysis
5/6 mm long threaded for metaphysis
B. Clamps 17

1) Universal Clamps
11) Open ended clamps
111) Transverse pin adjusting clamps
1v) Tube to tube clamps.

C. Tubes 11mm
Basic Components

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 Required instruments

Drill : Hand Drill

Drill bits – Long drill bits( 200mm) 3.5 and 4.5 mm

diameter.

Triple guide assembly , consist of trocar(3.5mm), inner

Sleeve and outer sleeve

T Handle for insertion of the Schanz pin.

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Required instruments

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 Indications
severe open fractures (Gustilo 3b,3c)
closed fractures with severe soft-tissue injury or severely
comminuted fractures or floating knee #
open fractures involving bone loss
compartment syndrome after fasciotomy
adjunct to internal fixation
limb lengthening or bone transport
fracture associated with severe burn
Arthrodesis
Infected fractures or nonunions
Correction of malunions
Fixation after radical tumor excision with autograft or allograft
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 External fixator as temporary device
Soft tissue healed
If the soft-tissue injuries
have healed satisfactorily
within 2 weeks without pin
track infection, the external
fixation can be removed.
It is then replaced by
internal fixation with either
a plate or a nail.

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 External fixator as temporary device
Soft-tissue problems persist
Remove the external fixator
Temporarily stabilize in cast
Let pin track infection heal

If there is pin track infection, using a nail (especially with

reaming technique) can lead to intramedullary infection.
In this case plate osteosynthesis is clearly preferable.

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 External fixation as final fixation

In the event that soft-tissue

healing is not satisfactory after
4-6 weeks, and there is no pin
track infection, the external
fixator can be left on until the
fracture has healed.

In children fracture healing is

often completed within a period
of approximately 6-8 weeks.

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External fixation as final fixation

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 Advantages

Less damage to blood supply of bone

Minimal interference with soft-tissue cover

Useful for stabilizing open fractures

Rigidity of fixation adjustable without surgery

Good option in situations with risk of infection

Requires less experience and surgical skill than
standard ORIF
Quite safe to use in cases of bone infection

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Complications

Pin Track Infection.

Neurovascular Impalement.
Muscle or Tendon Impalement
Delayed Union.
Compartment Syndrome
Re-fracture
Limitation of further Alternatives.
Cosmetic Problem

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 IM nails vs External fixator
Henley (Clin. Orth., 1989) randomised study of
104 case II-IIIB tibial fractures by unreamed IM nail;
70 treated by external fixation.
Infection rates 7% IM nail, 11% external fixation.
There was no difference in time to union.
Follow up in 1998 (Journal Orth. Trauma.): “The severity
of soft tissue injury rather than the choice of implant
appears to be the predominant factor influencing
rapidity of bone healing and rate of infection”.

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Site of insertion

Open fracture Tibia and Fibula

Open fracture Femur
Floating Knee
Open Fracture Humerus
Communited fracture distal Radius
Pelvic fracture.

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Tibial Safe Zone

Proximal part of the proximal tibia

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Tibial Safe Zone

Proximal 3rd distal to tibial tuberosity

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Tibial Safe Zone

Mid Shaft

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Tibial Safe Zone

Distal 3rd distal of tibial Shaft

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Schanz pin insertion

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Schanz Pin insertion for Metaphysis

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After adequate skin incision Insert assembled triple
sleeve and push onto bone.

Hold the sleeve steady and lightly tap the trocer on to

the bone surface in order to create the initial
impression. This prevents slipping of the drill bit during
drilling.

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Technique of Applications
Remove the trocar, insert the long 3.5 drill bit through
inner sleeve and drill through both cortices.

Withdraw the drill bit along with inner sleeve. Insert 4.5
mm drill bit through the outer sleeve and over drill the
near cortex.

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Technique of Applications
Place a 4.5 mm Schanz Pin onto the T-handle.
Introduce through the outer sleeve and insert into the
bone till the thread are securely engaged into the far
cortex.

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Technique of Applications for metaphysis
Insert the triple sleeve through an adequate skin
incision and push onto bone.

Drill the both cortex bone with 3.5 mm drill bit.

Insert 5mm long threaded Schanz Pin with T-handle.

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Application of external fixator
Place the most distal
Schanz Pin using the
standard technique.

Place a universal clamp

onto the schanz pin

Fix a 11mm tube in this

clamp, so that it is
posterior to the schanz
pin.

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 Application of external fixator…
Slide 3 Universal clamps
onto this tube.

Insert most proximal

schanz pin.

Reduction of bone.

Fix the proximal schanz

pin.

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 Application of external fixator…
Insert the 3rd 4th schanz
pin accordingly.

Connect frame with

another Tube.

Second tube is clamped

in “mirror image” fashion
after prestressing.

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In the OT

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In the OT

Open fracture Gustilo IIIB with Fixator

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In the OT

Flap Coverage

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Built as uni- and multi- plane constructs
Areas prone to soft tissue problems
◦ Knee
◦ Ankle
◦ Open Fractures
When multiple injuries prevent
definitive fixation

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Spanning ex- fix if axially unstable

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External fixation can
be combined with
internal fixation

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Temporary stabilization of long bone injuries in
unstable patient
◦ Minimally invasive
◦ Decreases bleeding
◦ Pain control
◦ Nursing care
◦ “Damage control”

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Certain intraarticular fracture can be treated by
ex-fix using traction by fixator on the capsule and
ligamentous structure around the joint.
This work well for comminuted intraarticular
fracture of the distal radius.

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Temporary stabilization for closed fractures
Controls hemorrhage
Decreases clot shear
Open pelvic fractures

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 Other External Fixators
Ilizarov External Fixator.

Universal Mini external Fixator.

Modular external Fixator

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Ilizarov External Fixator.

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Ilizarov External Fixator.

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Ilizarov External Fixator.

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

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The modular external fixator allows the
surgeon to reduce the fracture by
manipulation and to hold the reduction.
Free pin placement allows the surgeon:

◦ to spread both pins, thereby increasing

frame stiffness,
◦ to position pins according to the fracture
pattern or soft-tissue injury,
◦ to avoid injury to nerves or vessels.

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61
 Hoffman II external fixation system
Synthes Tibial exfix Adjustable

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External Fixator is a good device for the management of
open and complicated fractures.

Surgeon must have knowledge about neurovascular

plane of the involved Organ.

Skill for applying the fixator.

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Campbell’s operative orthopedics

Wheeless' Textbook of Orthopaedics

http://www.wheelessonline.com/ortho

Synthes: leading global medical device company.

http://us.synthes.com/
AO Foundation. <www.aofoundation.com>

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Thank You

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