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JUSH - TRAUMA UNIT - TEACHING

T H E E X T E R N A L F I X AT O R
PLAN

• Principles of the external


fixator

• Safe zones

• Tips and tricks


P R I N C I P L E S O F E X T E R N A L F I X AT I O N

• The external fixator should provide enough stability to


maintain reduction

• At least two pins have to be inserted into each main


fragment through the safe zone and in each segment ,
pins should be as far as possible
A V A N TA G E S O F E X T E R N A L F I X AT I O N

• less damage to the blood supply of the bone;

• minimal interference with soft-tissue cover

• rapid application in an emergency situation

• stabilization of open and contaminated fractures

• fracture reduction and stable fixation adjustable without surgery

• good solution in situations with high risk of infection or established infection

• less experience and surgical skill required than for standard ORIF

• image bone transport and deformity correction possible


I N D I C AT I O N S F O R E X T E R N A L F I X AT I O N

• External fixation is one option for the skeletal stabilization of open fractures,
in particular those with severe soft-tissue injury

• In closed fractures, external fixation is indicated for temporary bridging in


severe polytrauma and severe closed soft-tissue contusions or degloving

• External fixation should be considered for damage-control surgery in


polytrauma (ISS > 25) and it is probably the safest way to achieve initial
stabilization of fractures in the severly injured with an ISS > 40. It can be
performed rapidly and, because it is a minimally invasive technique, it will
minimize any additional surgical insult to the patient

• External fixation is recommended in cases of open or closed articular


fracture with severe soft-tissue compromise, when the external fixator can
be applied in a joint-bridging fashion
INSERTION TECHNIQUE

When inserting a Steinman pin or Schanz screw it is important to

• know the anatomy and avoid nerves, vessels, and tendons

• not place pins or screws into a joint

• avoid the fracture focus and hematoma

• predrill the cortex in order to avoid burning the bone (ring


sequestrum)

• insert a Schanz screw of the correct length


CONSTRUCTION TECHNIQUES

Different constructions of tubular external fixator which will produce increasing


levels of stability.

• a Unilateral uniplanar single-tube fixator.

• b Unilateral uniplanar single-tube modular fixator: a useful configuration with a


wide range of applications when using the modular reduction technique.

• c Unilateral uniplanar double tube fixator.

• d Unilateral biplanar frame (delta-frame).

• e Bilateral frame with transfixing pins that is now seldom used.


SAFE ZONES

In order to avoid injuries to nerves, vessels, tendons and muscles,


the surgeon must be familiar with the anatomy of the different
cross sections of the limb and make use of the safe zones for pin
placement
SAFE ZONE - TIBIA
SAFE ZONE - TIBIA

Proximal

medial is the safest

avoid the tibial crest

lateral is risky for the peroneal nerve

Distal

medial is the safest

lateral is risky for the tendons

Only in malleoli fractures, a single pin can inserted in the calcaneum, 



from medial to lateral. This fixation is not enough for tibia shaft fractures.
SAFE ZONE - FEMUR
SAFE ZONE - FEMUR

• Always lateral

• Never anterior !

• Be aware of the femoral artery


when you drill and screw the pin !
SAFE ZONE - HUMERUS
SAFE ZONE - HUMERUS - ULNA
!

Humerus
Proximal

safest is posterior or lateral

Distal

safest is posterior

Ulna

safest is directly 

on the ulnar crest
SCHANZ SCREW

• Schanz screws are partially threaded pins. These are


available in different diameters and lengths (shaft,
threaded part) and with different tips. Standard screws
have trocar-shaped tips. They require predrilling.
ROD

The AO fixators consist of systems in four sizes,


depending on the size of the rod :

11 mm tubes/rods with Schanz screws from 4 to 6 mm



8 mm tubes/rods with Schanz screws from 3 to 6 mm

4 mm tubes/rods with Schanz screws from 1.8 to 4 mm

2 mm system for fingers; it is presently available in the
conventional design and includes multipin clamps for K-
wires and 2 mm longitudinal rods.
CONSTRUCTION
P O S T O P E R AT I V E C A R E

Pin-track care starts with correct pin insertion.


Predrilling is recommended for the
conventional Schanz screw and the pin should
always be inserted by hand to reduce
thermal necrosis.

Undue soft-tissue tension around the pins must


be released during surgery. 


Correct care of the pin-track sites is important
to reduce the risk of pin-track complications. In
cases of persistent pin-track infection, the pin
has usually lost its firm hold in the bone. A seam
of bone resorption can be seen on the x-rays
and mechanically the pin appears to be loose.
This problem can be solved by removing such a
loose pin and placing a new one at another site.
P O S T O P E R AT I V E C A R E

• Keep any crust away from the


pin tract

• This allows for any secretion


to come out

• If secretions are trapped


under the skin, this creates
infection