Principles of External Fixation

PRINCIPLES OF EXTERNAL
FIXATION
BY SOPHIA ANKRAH
OVERVIEW
• Definition
• History
• Indications
• Advantages and Disadvantages
• Mechanics
• Biology
• Complications
DEFINITION
• A method of immobilising bones to allow a fracture to heal.
• Accomplished by placing pins or screws into the bone on both
sides of the fracture,
• which are then secured together outside the skin with clamps
and rods.
• The clamps and rods are known as the ‘external frame’.
• A surgical treatment used to set bone fractures in which a cast
would not allow proper alignment of the fracture.
HISTORY
• Almost 2400 years ago, Hippocrates described a form of
external fixation to splint a fracture of the tibia.
• The device consisted of closely fitting proximal and distal

Egyptian leather rings connected by 4 wooden rods on a
cornel tree.
HISTORY
• In 1840, Jean-Francois Malgaigne described a spike driven into
the tibia and held by straps to immobilise a fractured tibia.
• In 1843 he used a claw-like device to percutaneously hold the

fragments of a fractured patella.
HISTORY
• Clayton Parkhill of Denver, Colorado and Albine Lambotte of
Antwerp, Belgium, independently invented the modern
concept of unilateral external fixation in 1894 and 1902
respectively.
• Lambotte was the first to use threaded pins, however his

device necessitated initial open fracture reduction, and then
pin insertion and fixator placement.
HISTORY
• In 1938, Raoul Hoffman of Geneva, Switzerland built on the
work of others and developed a technique based on closed
reduction with guided percutaneous pin placement.
• Exemplified the first application of minimally invasive

orthopaedic surgery.
HISTORY
• In the 1950s, Gavril Ilizarov of
Kurgan, Soviet Union,
devised and developed a new
method of treating fractures.
• The procedure and the first

apparatus he designed for it
was inspired by a shaft bow
harness on a horse carriage.
• Originally, bicycle parts were

used for the frame
An Ilizarov apparatus
treating a fractured tibia
and fibula.
Also used to correct

angular deformity in the
leg, correct leg-length
differences, and treat non-
unions.
INDICATIONS
• TEMPORARY FRACTURE CARE
– Emergency stabilisation of a long bone fracture in the polytrauma
patient thought too unwell to have other interventions. ie ‘damage
control orthopaedics’
– Stabilisation of a dislocated joint after reduction. Eg. A spanning fixator

across the knee joint while the vascular surgeons repair an arterial
injury with a knee dislocation.
– Stabilisation of complex periarticular fractures to allow the soft tissues

to settle before definitive fixation. Eg distal tibial (pilon) fractures.
INDICATIONS
• DEFINITIVE FRACTURE CARE
– Open fractures
– Treating fractures with a bone loss
– Fractures associated with infection
– Periarticular fractures
– Paediatric fractures
– Pelvic ring fractures

INDICATIONS
• MALUNION/NONUNION
• ARTHRODESIS
• OSTEOMYELITIS
• LIMB DEFORMITY/LENGTH INEQUALITY

– Congenital or acquired
ADVANTAGES
• Minimally invasive
• No interference with fracture site
• Quick application ie rapid stabilisation of fracture
• Flexibility (build to fit)
• Adjustable after application (alignment, biomechanics)
• Soft tissues accessible for plastic surgery
• Hardware easy to remove
• Useful both as a temporising or definitive stabilisation device
DISADVANTAGES
• MECHANICAL
– Cumbersome for the patient
– Pin-bone interface failure
– Inadequate immobilisation
– Distraction of fracture site

DISADVANTAGES
• BIOLOGIC
– Infection
– Neurovascular injury
– Soft-tissue tethering
– Soft-tissue contracture
MECHANICS
• Components of the External Fixators
– Pins
– Clamps
– Connecting rods
PINS
• Principle : Critical link between the bone and the frame
• Various diameters, lengths and designs
• Materials
– Stainless steel
– Titanium ( more biocompatible, less stiff)
• Pin coatings
– Chlorohexidine, silver,hydroxyapatite
• Pin insertion technique
– Avoid soft tissue damage
CLAMPS
• PRINCIPLES
– Must securely hold the frame
to the pin
– Clamps placed closer to bone

increases the stiffness of the
entire fixator construct
CONNECTING RODS
• PRINCIPLE
– Increased diameter =
increased stiffness and
strength
– Stacked (2 parallel bars) =
increased stiffness
FRAME TYPES
• Standard frame
• Joint spanning frame
• Distraction or correction frame

Standard frame Joint spanning frame
RING FIXATORS
• Components:
– Tensioned thin wires
• olive or straight
– Wire and half pin clamps
– Rings
– Rods
– Motors and hinges
• Combines components of
the standard ex fixator with
a ring frame construct
• Correction of length, angulation
and rotation
HYBRID FIXATORS
• Combines the advantages of
ring fixators in periarticular
areas with simplicity of
planar half pin fixators in
diaphyseal bone
BIOLOGY
• Fracture healing is by micromotion and dynamisation.
• Micromotion leads to callus formation
• Dynamisation is the load-sharing construct that promote
micromotion at the fracture site.
• It is the gradual addition of increasing load across the site of
osteogenesis, and it results in greater callus formation.
• Accomplished by destabilising the frame
COMPLICATIONS
• Pin-track infection/loosening
• Frame or Pin/Wire failure
• Malunion
• Non-union
• Soft-tissue impalement
• Compartment syndrome
• Septic arthritis
• Avoid intracapsular wires
• Stiffness of adjacent joint
• If joint has been spanned for sometime and during lengthening procedures
PIN-TRACK INFECTION
• Most common complication
• 4 stages
• Prevention is by proper
pin/wire insertion
technique
– Fixator pins away from zone
of injury to minimise/avoid
contamination of fracture site
• Adequate post-op care
– Clean, saline, gauze, shower
• Treatment according to
stage
PIN LOOSENING
• Factors that influence include
– Pin track infection/osteomyelitis
– Thermonecrosis
– Delayed union or non-union
• Prevention is by proper insertion techniques
• Treatment is by replacing/removing loose pin
FRAME FAILURE
• Rare
• Theoretically can occur with recycling of old frames
• However no proof that frames cannot be re-used
MALUNION
• Intra-operative causes:
– Poor technique
• Prevention is by clear pre-op planning
• Treatment is by adjusting or reapplying frame prior to union(if
early), or reconstructive correction of malunion( if late)
• Post-operative causes:
– Frame failure
• Prevention is by proper follow up
• Treatment is by osteotomy/reconstruction
NON-UNION
Minimised by:
• Avoiding distraction at fracture site
• Early bone grafting
• Good surgical technique
• Control infections
SOFT-TISSUE IMPALEMENT
• Tethering of soft tissues can result in:
– Loss of motion
– Scarring
– Vessel injury
• Prevention
– Avoid piercing muscle or tendons
– Position joint in neutral
COMPARTMENT SYNDROME
• Rare
• Cause
– Injury related
– Pin or wire causing intracompartmental bleeding
• Prevention
– Clear understanding of the anatomy
– Good technique
– Post-op vigilance
SUMMARY
• Different reasons and modes of application of external fixators
• Choose appropriate mode for particular situation
• For excellent results, appropriate use, good technique, Good
Technique and GOOD TECHNIQUE are required!
• Recognise and correct complications early
REFERENCES
• Baily and Love
• PPT by Roman Hayda
• en.wikipedia.org
• www.wheelessorthopaedics.com
• Lecture notes 2010/2011
s! ! !
G ra c ia
u c h as
M

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PRINCIPLES OF EXTERNAL

• The device consisted of closely fitting proximal and distal

• In 1843 he used a claw-like device to percutaneously hold the

• Lambotte was the first to use threaded pins, however his

• Exemplified the first application of minimally invasive

• The procedure and the first

• Originally, bicycle parts were

Also used to correct

– Stabilisation of a dislocated joint after reduction. Eg. A spanning fixator

– Stabilisation of complex periarticular fractures to allow the soft tissues

– Treating fractures with a bone loss

– Fractures associated with infection

– Pelvic ring fractures

• LIMB DEFORMITY/LENGTH INEQUALITY

– Pin-bone interface failure

– Distraction of fracture site

– Clamps placed closer to bone

• Joint spanning frame

• Distraction or correction frame

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