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External Fixation Indications and Techniques
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Objectives Identify the following as they pertain to external fixation: Advantages & disadvantages Indications Types of frames Biomechanics stability Pre-operative planning Common complications
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External Fixator A device placed outside the skin that stabilizes bone fragments with pins or wires connected to bars “Relative stability “ Healing with callus
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External Fixation Advantages
Minimal damage to blood supply Minimal damage to soft tissues Fixation is away from site of injury Good option when significant infection risk
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External Fixation Disadvantages
Restricted joint motion Pin tract infection Cumbersome Inadequate stability for certain fractures
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Indications Most commonly used: Less commonly used: Tibia
Distal radius Less commonly used: Femur Humerus Forearm
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Indications Open fractures
Closed fractures with soft tissue compromise Periarticular fractures Polytrauma/Damage control Pelvic fractures Children’s fractures
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Open Fractures Avoids injury site
Avoids additional injury to soft tissues and vascularity
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Open Fractures
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Open Fractures Segmental bone loss
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Open Fractures Fractures needing nerve or vessel repair
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Closed Fractures with Soft Tissue Compromise
Swelling Fracture blisters
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Closed Fractures with Soft Tissue Compromise
Crush injuries Burns
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Closed Fractures with Soft Tissue Compromise
Compartment syndrome
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Periarticular Fractures
Severe fractures with joint involvement and shaft extension
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Periarticular Fractures
Spanning ex-fix if axially unstable
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Periarticular Fractures
Hybrid Fixator: Thin wires near joint Pins (Schanz Screws) in shaft
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Periarticular Fractures
Reduce and fix the joint surface Span the diaphyseal segment without disturbing soft tissues
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Periarticular Fractures
External fixation can be combined with internal fixation
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Polytrauma Temporary stabilization of long bone injuries in unstable patient Minimally invasive Decreases bleeding Pain control Nursing care “Damage control”
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Pelvic Fractures Temporary stabilization for closed fractures
Controls hemorrhage Decreases clot shear
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Pelvic Fractures Open pelvic fractures = “The lethal injury”
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Pelvic Fractures Quick application Open or percutaneous pin insertion
Easily removed for definitive ORIF
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Children’s Fractures Femoral fractures
One alternative to weeks of skeletal traction Used less with use of flexible nails
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Children’s Fractures Pin placement must avoid growth plate
Watch for pin tract infection Occasional joint stiffness
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External Fixation Fixator construct will depend on treatment strategy:
Emergency care Provisional care Definitive care
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External Fixator Constructs
Uni-plane Bi-plane Multi-plane Ring
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Uni-plane Bi-plane Multi-plane
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Uni-plane Fixator Single Bar
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Uni-plane Fixator “Z Frame”
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Uni-plane Fixator Double Stacked
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Bi-plane Fixator
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Multi-plane Fixator
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Spanning External Fixation
Built as uni- and multi- plane constructs Areas prone to soft tissue problems Knee Ankle Open Fractures When multiple injuries prevent definitive fixation Animation. 1st click. Title and graphic Bullets come in separately.
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Spanning Ex Fix Adjunct to Internal Fixation Temporary Definitive
Animation. 1st click. Title and graphic Bullets come in separately.
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Increase Stability Pins Larger diameter More pins
Closer to fracture site
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Increase Stability Bars: Closer to limb More bars
Second plane at right angle to decrease torsion (twisting)
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Increase Stability Rings: Smaller is stiffer More rings = more stable
Use smallest diamaeter ring possible but allow for swelling More rings = more stable
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External Fixation Anatomy
Safe pin placement “Safe corridors” Know your anatomy to safely place pins!
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Intraop Setup Circumferential prep of entire limb Radiolucent table
C-arm
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Intraop Setup Associated procedures Irrigation Debridement
Internal Fixation Bone graft
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Intraop Setup Adequate fixator components Cannulated screws
Large/small fragment sets
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Intraop Technique Keep bars close to bone but…
. . . allow access for soft tissue care Allow for swelling Can be re-adjusted as needed
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Complications Neurovascular injury Pin loosening Pin tract infection
Joint stiffness Malalignment Malunion Nonunion
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Complications Pin tract infections: Most common complication
Avoid fracture area Don’t “burn” bone – pre-drill Insert pin completely Release skin
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Complications Know where pins are going!
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THANK YOU!
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