Principles of External Fixation

Roman Hayda, MD
Original Authors: Alvin Ong, MD & Roman Hayda, MD; March 2004;
New Author: Roman Hayda, MD; Revised November, 2008
 Overview
• Indications
• Advantages and disadvantages
• Mechanics
• Biology
• Complications
 Indications
• Definitive fx care: • Malunion/nonunion
• Open fractures
• Arthrodesis
• Peri-articular fractures
• Osteomyelitis
• Pediatric fractures
• Temporary fx care • Limb
• “Damage control”
deformity/length
– Long bone fracture temporization
inequality
• Pelvic ring injury • Congenital
• Periarticular fractures • Acquired
– Pilon fracture
 Advantages

• Minimally invasive
• Flexibility (build to fit)
• Quick application Complex 3-C humerus fx

• Useful both as a temporizing or definitive

stabilization device
• Reconstructive and salvage applications
 Disadvantages
• Mechanical
– Distraction of fracture site
– Inadequate immobilization
–
–
Pin-bone interface failure May result in
Weight/bulk
– Refracture (pediatric femur) malunion/nonunion,
• Biologic loss of function
– Infection (pin track)
• May preclude conversion to IM nailing or internal fixation
– Neurovascular injury
– Tethering of muscle
– Soft tissue contracture
Components of the Ex-fix

• Pins

• Clamps

• Connecting rods
 Pins
• Principle: The pin is the critical link between
the bone and the frame
– Pin diameter
• Bending stiffness
proportional to r4
• 5mm pin 144% stiffer < 1/3 dia
than 4mm pin
– Pin insertion technique respecting bone and soft
tissue
 Pins
• Various diameters, lengths,
and designs
– 2.5 mm pin
– 4 mm short thread pin
– 5 mm predrilled pin
– 6 mm tapered or conical pin
– 5 mm self-drilling and self tapping
pin
– 5 mm centrally threaded pin
• Materials
– Stainless steel
– Titanium
• More biocompatible
• Less stiff
 Pin Geometry
‘Blunt’ pins
- Straight
- Conical

Self Drilling and Tapping

 Pin coatings
• Recent development of various coatings
(Chlorohexidine, Silver, Hydroxyapatite)
– Improve fixation to bone
– Decrease infection

– Moroni, JOT, ’02

• Animal study, HA pin 13X higher extraction torque vs
stainless and titanium and equal to insertion torque
– Moroni, JBJS A, ’05
• 0/50 pts pin infection in tx of pertrochanteric fx
 Pin Insertion Technique
1.Incise skin
2.Spread soft tissues to
bone
3.Use sharp drill with
sleeve
4.Irrigate while
drilling
5.Place appropriate pin
using sleeve
Avoid soft tissue damage and bone
thermal necrosis
 Pin insertion
•Self drilling pin
considerations
– Short drill flutes
• thermal necrosis
• stripping of near vs.
cortex with far cortex
contact
– Quick insertion
– Useful for short term
applications
 Pin Length
•Half Pins
–single point of entry
–Engage two cortices
•Transfixation Pins
–Bilateral, uniplanar fixation
–lower stresses at pin bone
interface
–Limited anatomic sites (nv
injury)
–Traveling traction
Courtesy Matthew Camuso
 Pin Diameter Guidelines

•Femur – 5 or 6 mm
•Tibia – 5 or 6 mm
•Humerus – 5 mm
•Forearm – 4 mm
•Hand, Foot – 3 mm

< 1/3 dia

Slide courtesy Matthew Camuso

 Clamps
• Two general varieties:
– Single pin to bar clamps
– Multiple pin to bar clamps
• Features:
– Multi-planar adjustability
– Open vs closed end

• Principles
– Must securely hold the
frame to the pin
– Clamps placed closer to
bone increases the
stiffness of the entire
fixator construct
 Connecting Rods and/or Frames
• Options:
– materials:
• Steel
• Aluminum
• Carbon fiber
– Design
• Simple rod
• Articulated
• Telescoping

• Principle
– increased diameter = increased stiffness and strength
– Stacked (2 parallel bars) = increased stiffness
 Bars
•Stainless vs Carbon
Fiber Added bar stiffness
–Radiolucency
≠
–↑ diameter = ↑ stiffness increased frame stiffness
–Carbon 15% stiffer vs
stainless steel in loading to
failure
–frames with carbon fiber
are only 85% as stiff ? ? ? ?
Weak link is clamp to
carbon bar?
Kowalski M, et al, Comparative Biomechanical Evaluation of Different External Fixator Sidebars: Stainless-Steel Tubes
versus Carbon Fiber Bars, JOT 10(7): 470-475, 1996
 Ring Fixators

• Components:
– Tensioned thin wires
• olive or straight
– Wire and half pin clamps
– Rings
– Rods
– Motors and hinges (not
pictured)
 Ring Fixators
• Principles:
– Multiple tensioned thin wires (90-
130 kg)
– Place wires as close to 90 to
o

each other
– Half pins also effective
– Use full rings (more difficult to
deform)
• Can maintain purchase in
metaphyseal bone
• Allows dynamic axial
loading
• May allow joint motion
 Multiplanar Adjustable Ring
Fixators
• Application with wire or half pins
• Adjustable with 6 degrees of freedom
– Deformity correction
• acute
• chronic
• Type 3A open tibia fracture with bone loss
• Following frame adjustment and bone
grafting
 Frame Types
• Uniplanar
– Unilateral
– Bilateral
• Pin transfixes extremity
• Biplanar
– Unilateral
– Bilateral
• Circular (Ring
Fixator)
– May use Half-pins and/or
transfixion wires
• Hybrid Unilateral uniplanar Unilateral biplanar
– Combines rings with planar
frames
 Hybrid Fixators
• Combines the
advantages of ring
fixators in periarticular
areas with simplicity
of planar half pin
fixators in diaphyseal
bone

From Rockwood and Green’s, 5th Ed

 Biomechanical Comparison
Hybrid vs Ring Frames
• Ring frames resist axial and bending
deformation better than any hybrid
modification
• Adding 2nd proximal ring and anterior half
pin improves stability of hybrid frame
Clinical application: Use full ring fixator for fx
with bone defects or expected long frame time
Pugh et al, JOT, ‘99
Yilmaz et al, Clin Biomech, 2003
Roberts et al, JOT, 2003
 MRI Compatability
• Issues:
– Safety
• Magnetic field displacing ferromagnetic object
– Potential missile
• Heat generation by induced fields
– Image quality
• Image distortion
 MRI Compatibility
• Stainless steel components (pins, clamps, rings) most
at risk for attraction and heating
• Titanium (pins), aluminum (rods, clamps, rings) and
carbon fiber (rods, rings) demonstrate minimal
heating and attraction
• Almost all are safe if the components are not directly
within the scanner (subject to local policy)
• Consider use of MRI “safe” ex fix when area interest
is spanned by the frame and use titanium pins

Kumar, JOR, 2006

Davison, JOT, 2004
Cannada, CORR, 1995
 Frame Types
• Standard frame

• Joint spanning frame:

– Nonarticulated
– Articulated frame

• Distraction or Correction frame

 Standard Frame
• Standard Frame
Design
– Diaphyseal region
– Allows adjacent
joint motion
– Stable
 Joint Spanning Frame
• Joint Spanning Frame
– Indications:
• Peri-articular fx
– Definitive fixation through
ligamentotaxis
– Temporizing
» Place pins away from
possible ORIF incision sites
• Arthrodesis
• Stabilization of limb with
severe ligamentous or vascular
injury: Damage control
 Articulated Frame
• Articulating Frame
– Limited indications
• Intra- and peri-articular fractures or ligamentous
injury
• Most commonly used in the ankle, elbow and knee
– Allows joint motion
– Requires precise placement of hinge in the axis of
joint motion

(Figure from: Rockwood and Green, Fractures in Adults, 4 th ed, Lippincott-Raven, 1996)
 Correction of Deformity or Defects

• May use unilateral or ring frames

• Simple deformities may use simple frames
• Complex deformities require more complex
frames
• All require careful planning
• 3B tibia with segmental bone loss, 3A
plateau, temporary spanning ex fix
• Convert to circular
frame, orif plateau
• Corticotomy and
distraction
• Consolidation
*note: docking site bone grafted
Healed
 EXTERNAL FIXATION
Biomechanics

Leave the Eiffel tower in Paris!

Understand fixator mechanics
• do not over or underbuild frame!
 Fixator Mechanics:
Pin Factors
• Larger pin diameter
• Increased pin spread
– on the same side of the fracture
• Increased number of pins
(both in and out of plane
of construct)
 Fixator Mechanics:
Pin Factors
• Oblique fxs subject to
shear
• Use oblique pin to
counter these effects

Metcalfe, et al, JBJS B, 2005

Lowenberg, et al, CORR, 2008
 Fixator Mechanics: Rod Factors
• Frames placed in the same plane as the applied load
• Decreased distance from bars to bone
• Stacking of bars

 
 Frame Mechanics:
Biplanar Construct
• Linkage between
frames in
perpendicular planes
(DELTA)
• Controls each plane of
deformation
 Frame Mechanics: Ring Fixators


• Spread wires to as
o
close to 90 as
anatomically
possible
• Use at least 2 planes
of wires/half pins in
each major bone
segment
 Modes of Fixation
• Compression
– Sufficient bone stock
– Enhances stability
– Intimate contact of bony ends
– Typically used in arthrodesis or to complete union of a fracture
• Neutralization
– Comminution or bone loss present
– Maintains length and alignment
– Resists external deforming forces
• Distraction
– Reduction through ligamentotaxis
– Temporizing device
– Distraction osteogenesis
 Biology
• Fracture healing by stable
yet less rigid systems
– Dynamization
– Micromotion
• micromotion = callus
formation

(Figures from: Rockwood and Green,

Kenwright, CORR, 1998 Fractures in Adults, 4th ed,
Larsson, CORR, 2001 Lippincott-Raven, 1996)
 Biology
• Dynamization = load-
sharing construct that
promote micromotion at
the fracture site
• Controlled load-sharing
helps to "work harden" the (Figures from: Rockwood and Green,
fracture callus and Fractures in Adults, 4th ed,
Lippincott-Raven, 1996)
accelerate remodeling
•Kenwright and Richardson, JBJS-B, ‘91
•Quicker union less refracture
•Marsh and Nepola, ’91
•96% union at 24.6 wks
 Anatomic Considerations
• Fundamental knowledge of the anatomy is critical
• Avoidance of major nerves,vessels and organs
(pelvis) is mandatory
• Avoid joints and joint capsules
– Proximal tibial pins should be placed 14 mm distal to articular
surface to avoid capsular reflection
• Minimize muscle/tendon impalement (especially
those with large excursions)
 Lower Extremity “safe” sites
14 mm

• Avoid
– Nerves
– Vessels
– Joint capsules
• Minimize
– Muscle transfixion
 Upper Extremity “Safe” Sites
• Humerus: narrow lanes
– Proximal: axillary n
– Mid: radial nerve
– Distal: radial, median and ulnar n
– Dissect to bone, Use sleeves
• Ulna: safe subcutaneous border, avoid
overpenetration
• Radius: narrow lanes
– Proximal: avoid because radial n and PIN, thick muscle sleeve
– Mid and distal: use dissection to avoid sup. radial n.
 Damage Control and Temporary
Frames
• Initial frame application rapid
• Enough to stabilize but is not
definitive frame!
• Be aware of definitive
fixation options
– Avoid pins in surgical approach sites
• Depending on clinical
situation may consider
minimal fixation of articular
surface at initial surgery
 Conversion to Internal Fixation
• Generally safe within 2-3 wks
– Bhandari, JOT, 2005
• Meta analysis: 6 femur, 9 tibia, all but one retrospective
• Infection in tibia and femur <4%
• Rods or plates appropriate
• Use with caution with signs of pin irritation
– Consider staged procedure
• Remove and curette sites
• Return following healing for definitive fixation
– Extreme caution with established pin track infection
– Maurer, ’89
• 77% deep infection with h/o pin infection
 Evidence
• Femur fx
– Nowotarski, JBJS-A, ’00
• 59 fx (19 open), 54 pts,
• Convert at 7 days (1-49 days)
• 1 infected nonunion, 1 aseptic
nonunion
– Scalea, J Trauma, ’00
Bilat open femur, massive
• 43 ex-fix then nailed vs 284 compartment syndrome, ex fix
primary IM nail then nail
• ISS 26.8 vs 16.8
• Fluids 11.9l vs 6.2l first 24
hrs
• OR time 35 min EBL 90cc vs
135 min EBL 400cc
• Ex fix group 1 infected
nonunion, 1 aseptic nonunion
 Evidence

• Pilon fx
– Sirkin et al, JOT, 1999
• 49 fxs, 22 open
• plating @ 12-14 days,
• 5 minor wound problems, 1 osteomyelitis
– Patterson & Cole, JOT, 1999
• 22 fxs
• plating @ 24 d (15-49)
• no wound healing problems
• 1 malunion, 1 nonunion
 Complications
• Pin-track infection/loosening
• Frame or Pin/Wire Failure
• Malunion
• Non-union
• Soft-tissue impalement
• Compartment syndrome
 Pin-track Infection
• Most common
complication
• 0 – 14.2% incidence
• 4 stages:
– Stage I: Seropurulent
Drainage
– Stage II: Superficial
Cellulitis
– Stage III: Deep Infection
– Stage IV: Osteomyelitis
 Pin-track Infection
Union Fx infection Malunion Pin Infection
Mendes, ‘81 100% 4% NA 0

Velazco, ’83 92% NA 5% 12.5%

Behrens, ’86 100% 4% 1.3% 6.9%

Steinfeld, ’88 97% 7.1% 23% 0.5%

Marsh, ‘91 95% 5% 5% 10%

Melendez, ’89 98% 22% 2% 14.2%

 Pin-track Infection
• Prevention:
– Proper pin/wire insertion technique:
• Subcutaneous bone borders
• Away from zone of injury
• Adequate skin incision
• Cannulae to prevent soft tissue injury
during insertion
• Sharp drill bits and irrigation to
prevent thermal necrosis
• Manual pin insertion
(Figures from: Rockwood and
Green, Fractures in Adults, 4th ed,
Lippincott-Raven, 1996)
 Pin-track Infection
• Postoperative care:
– Clean implant/skin
interface
– Saline
– Gauze
– Shower
 Pin-track Infection
• Treatment:
– Stage I: aggressive pin-site care and oral cephalosporin
– Stage II: same as Stage I and +/- Parenteral Abx
– Stage III: Removal/exchange of pin plus Parenteral
Abx
– Stage IV: same as Stage III, culture pin site for
offending organism, specific IV Abx for 10 to 14 days,
surgical debridement of pin site
 Pin Loosening
• Factors influencing Pin
Loosening:
– Pin track infection/osteomyelitis
– Thermonecrosis
– Delayed union or non-union
– Bending Pre-load
 Pin Loosening
• Prevention:
– Proper pin/wire insertion techniques
– Radial preload
– Euthermic pin insertion
– Adequate soft-tissue release
– Bone graft early
– Pin coatings
• Treatment:
– Replace/remove loose pin
 Frame Failure
• Incidence: Rare
• Theoretically can occur with recycling of
old frames
• However, no proof that frames can not be
re-used
 Malunion
Intra-operative causes:
– Due to poor technique
• Prevention:
– Clear pre-operative planning
– Prep contralateral limb for comparison
– Use fluoroscopic and/or intra-operative films
– Adequate construct
• Treatment:
– Early: Correct deformity and adjust or re-apply frame prior to
bony union
– Late: Reconstructive correction of malunion
 Malunion
Post-operative causes:
– Due to frame failure
• Prevention:
– Proper follow-up with both clinical and radiographic
check-ups
– Adherence to appropriate weight-bearing restrictions
– Check and re-tighten frame at periodic intervals
• Treatment:
– Osteotomy/reconstruction
 Non-union
• Union rates comparable to those achieved with
internal fixation devices
• Minimized by:
– Avoiding distraction at fracture site
– Early bone grafting
– Stable/rigid construct
– Good surgical technique
– Control infections
– Early wt bearing
– Progressive dynamization
 Soft-tissue Impalement
• Tethering of soft tissues can result in:
– Loss of motion
– Scarring
– Vessel injury
• Prevention:
– Check ROM intra-operatively
– Avoid piercing muscle or tendons
– Position joint in NEUTRAL
– Early stretching and ROM exercises
 Compartment Syndrome

• Rare
• Cause:
– Injury related
– pin or wire causing intracompartmental bleeding
• Prevention:
– Clear understanding of the anatomy
– Good technique
– Post-operative vigilance
 Future Areas of Development
• Pin coatings/sleeves
– Reduce infection
– Reduce pin loosening
• Optimization of dynamization for fracture
healing
• Increasing ease of use/reduced cost
 Construct Tips
• Chose optimal pin diameter
• Use good insertion technique
• Place clamps and frames close to skin
• Frame in plane of deforming forces
• Stack frame (2 bars)
• Re-use/Recycle components (requires
certified inspection).

Plan ahead!
 Summary
• Multiple applications
• Choose components and geometry suitable
for particular application
• Appropriate use can lead to excellent results
• Recognize and correct complications early

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 References
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Based Orthopaedic Trauma , JOT, 19(2): 40-144, 2005.
2. Cannada LK, Herzenberg JE, Hughes PM, Belkoff S. Safety and Image Artifact of External Fixators and Magnetic Resonance Imaging. CORR, 317, 206-214:1995.
3. Davison BL, Cantu RV, Van Woerkom S. The Magnetic Attraction of Lower Extremity External Fixators in an MRI Suite. JOT, 18 (1): 24-27, 2004.
4. Kenwright J, Richardson JB, Cunningham, et al. Axial movement and tibial fractures. A controlled randomized trial of treatment, JBJS-B, 73 (4): 654-650, 1991.
5. Kenwright J , Gardner T. Mechanical influences on tibial fracture healing. CORR, 355: 179-190,1998.
6. Kowalski, M et al, Comparative Biomechanical Evaluation of Different External Fixator Sidebars: Stainless-Steel Tubes versus Carbon Fiber Bars, JOT 10(7): 470-
475, 1996.
7. Kumar R, Lerski RA, Gandy S, Clift BA, Abboud RJ. Safety of orthopedic implants in Magnetic Resonance Imaging: an Experimental Verification. J Orthop Res, 24
(9): 1799-1802, 2006.
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9. Lowenberg DW, Nork S, Abruzzo FM. The correlation of shearing force with fracture line migration for progressive fracture obliquities stabilized by external fixation
in the tibial model. CORR, 466:2947–2954, 2008.
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Fractures. Review of Two Consecutive Series , JOT, 5(3): 341-348, 1991.
11. Maurer DJ, Merkow RL, Gustilo RB. Infection after intramedullary nailing of severe open tibial fractures initially treated with external fixation. JBJS-A, 71(6), 835-
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87 (6): 868-872, 2005.
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