External Fixator in Orthopaedics and

Traumatology
Adesina Ajibade FWACS
OUTLINE
1. Introduction
2. Historical Account
3. Definitions
4. Basic components
5. Types of external Fixators
6. Indications and Use of External Fixators
7. Principles of Application
8. Complications
9. Conclusion
Brief History
Malgaigne (1853/64)
– metal point and claws
Parkhill of Denver and Lambotte of Brussels (1907)
– 1st clinically useful Exfix
Codivilla (1905) & Putti (1918)
- Pins and plasters for leg lengthening
The 1930s – Introduction of
Transfixion pins
Longitudinal distraction
Compression mechanism
Universal articulations
Definitions
External Fixation
Manipulation, aligning and stabilising bony structures
with pins, wires, screws or other fasteners that affix
the bone to an external scaffold or frame

External Device
The external scaffold or frame with the fasteners
which affix it to bone
Basic Components
Brief History
Anderson (1936), Stader (1937), and Hoffman
(1954)
- Sophisticated devices following the advancements of
the 1930s
Ilizarov (after WWII)
- Ring fixators
Part of AO instrumentarium
Wagner device (1972)
Weber fixator threaded rods (1985)
Types of External Fixators
Behren’s Classification (1989)
1. Pin fixators
a. Simple pin fixators

b. Clamp fixators

2. Ring fixators
 Types of External Fixators (Behrens, 1989)
SIMPLE PIN FIXATORS
Fasteners attached to a longitudinal rod by independent articulations
Examples: Orthofix, AO/ASIF
Types of External Fixators: Simple Pin Fixators
Advantages
Latitude in pin placement
Many configurations possible
Possible Configurations with Simple Pin Fixators
 Types of External Fixators: Simple Pin Fixators
Disadvantage
Permits only little adjustment after applications i.e # must be
reduced before application

Modular unilateral frame

With universal joints/tube-to-tube
Clamps takes care of the disadvantage
Types of External Fixators: Clamp Fixators

Fasteners are connected to clamps which are then attached to longitudinal

Rod by means of an articulation

Example: Hoffman device

Types of External Fixators: Clamp Fixators
Advantage
Final fracture adjustment can be done after
application of device
Disadvantages
No latitude in pin placement and direction
(determined by the clamps)
Finite possible configurations
Inherent danger of losing reduction on releasing
articulations
Types of External Fixators: Ring Fixators
A frame of rings or partial rings connected by rods and fastened
To bones, usually with tensioned wires

Example: Ilizarov device

Types of External Fixators: Ring Fixators
Advantage
Gradual and precise correction of angulation and
rotational deformity
Disadvantages
Limitation of access to wounds
Free tissue transfer difficult or impossible to do
Multiple scars from multiple pins
Hybrid Fixators
Hybrid components for coupling unilateral half –
pin fixators with ilizarov frames
Some unilateral half-pin fixators have attachments
that permit coupling with ring components
Especially useful in the diaphysis
Advantages:
No transfixion
Elimination of thermal necrosis due to K-wires in
cortical bone
 Indications in Trauma
1. Fractures with severe soft tissue injuries e.g Gustilo Type III open fractures
 Indications in Trauma
2. Pelvic trauma with haemodynamic instability
 Indications in Trauma
. Severely comminuted and unstable fractures
3
Indications in Trauma
4. Fractures with associated neurovascular injury
e.g. Gustilo Type IIIC open fracture
5. Infected fractures
a. Infected open fractures
b. Infected non-union
6. Polytrauma
7. Reconstruction after limb trauma
 Bone transport
 Bone lengthening
 Indications in Orthopaedics

1. Bone lengthening e.g old physeal injuries with LLD

2. Bone transport e.g treatment congenital pseudoarthrosis of the tibia
 Indications in Orthopaedics
3. Correction of soft tissue deformities e-g relapsed or neglected CTEV
 Indications in Orthopaedics

4. Correction of bony deformities by osteotomy

Indications in Orthopaedics
5. Arthrodesis
6. Management of unicompartmental OA of
The knee by hemicallotasis
Uses in Orthopaedics and Traumatology
1. Access to wounds for dressing and secondary
procedures
2. Maintenance of length in traumatic bone loss
3. Fracture stabilization (usually temporary)
4. Rapid achievement of haemodynamic stability in
pelvic fractures
5. Correction of deformity
6. Treatment of limb length inequality
7. Joint fusion
 Principles of External Fixation
1. Application in safe corridor

Safe corridor and arc of insertion in the leg

Arc varies from 1200 to 2200 from distal
to proximal part
Principles of External Fixation
2. Placement to allow access to injured site for
a. Primary procedure (initial debridement)
b. Secondary procedure
i. Transfer of pedicled/free soft tissue flaps
ii. Sequestrectomy
iii. Bone grafting
In open fracture management
Principles of External Fixation
3) Consideration of frame stability vis-a-vis motion
at fracture site (Seven ‘Ss’)
i. Saggital plane
ii. Increase spread of Schantz screws
iii. Oversizing of core of Schantz screw by about 0.2mm
(Radial preload)
iv. Raise number of Schantz screws
v. Shrink rod-bone distance
vi. Second tube in the same plane close to the first
vii. Second half-frame in second plane in same corridor
 Principles of External Fixation
Circular-ring and tensioned-wire devices;
1.a. Proper tensioning of wires(90–130
kg).
2.b. Placing wires perpendicular to each
other as much as possible while still being
mindful of neurovascular anatomy

1. Wires at right angle:

deformation of bony FF resisted in both
AP and ML planes
2. Wires not at right angle offer less
resistance to forces in the unopposed AP
plane
Complications
Soft tissue impalement/tethering
Skin tenting
Pin loosening – A race between achieving the aim of
application and pin loosening
Fixator body/frame failure - breakage or bending
Malunion
Non-union
Compartment syndrome – Unclear if due to the
external fixator or the preexisting injury
Complications: Pin track Infections
Stage I: Serous or Seropurulent discharge
Free-flowing serous discharge or pus pathologic
Pin site hygiene +Broad spectrum A/B (1st gen
cephalosporin)
Stage II: Superficial cellulitis
A halo of erythema around site
Treatment as in stage I
Poor response – give parenteral A/B
Complications: Pin track Infections
Stage III: Deep Infection
Rare
Deep seated infection along the entire pin track
Pus, swelling , severe cellulitis
More than one pin in a cluster affected
Treatment:
 Remove loose implants
 Antibiotics
 Pin/Screw re-insertion after infection control
Complications: Pin track Infections
Stage IV: Osteomyelitis
Implants critically loose
X-ray evidence of bone inefection
Acute infection
 Remove hardware
 Parenteral A/B for 2 weeks
Ring sequestrum
 Remove hardware
 Overdrilling, curretage and irrigation of pin track
 Protect limb from weight bearing for 4 – 6 weeks
 Antibiotics
Preventing pin track infection
 Mechanical stability
 Pin care
Henry C. Pin sites: do we need to clean them? Practice
Nursing. 1996;7:12,15-17.
- No pin site care better than care with cleansing solutions
Moroni A, Vannini F, Mosca M, Giannini S. State of the
art review: techniques to avoid pin loosening and
infection in external fixation. J Orthop Trauma.
2002;16:189-95.
Preventing pin track infection
 Pin care
Henry C. Pin sites: do we need to clean them? Practice
Nursing. 1996;7:12,15-17.
- No pin site care better than care with cleansing solutions
Preventing pin track infection
Pin care

W-Dahl A, Toksvig-Larsen S, Lindstrand A. No

Difference Between Daily and Weekly Pin Site Care:
A Randomized Study of 50 Patients with External
Fixation. Acta Orthop Scand. 2003 Dec;74:704-8.

- Summary in next slide.

Preventing pin track infection
W-Dahl A, Toksvig-Larsen S and Lindstrand A
N=50
Weekly care: n=23; Daily care: n=27.
Main outcome measures: Infection rate, severity of
infection
Results
Frequency and severity of infection – No difference
Infection Weekly care Daily care Difference
@10wks 8.0% 9.3% 1.3%(-7.4 to 9.5)
@ pin extraction 12.0% 10,2% 1.8%(-1.1 to 7.1)
 Classification of pin loosening (Burny et al)

Stage Description
1 Perfect anchorage; no perceptible motion between pin and
bone
2 Slight motion between pin and bone (Sensation of ‘contact’ on fast
oscillation by hand)
3 Considerable motion between pin and bone (Clinical loosening)

4 Possibility of manual extraction (or spontaneous pull-out) of pin

CONCLUSION
External fixators have evolved from the 19 th
century to the present to an invaluable treatment
armamentarium in orthopaedics and traumatology