(9)external fixation indications and techniques(bonatus)
TRANSCRIPT
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External FixationExternal FixationIndicationsIndications
and Techniquesand Techniques
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ObjectivesObjectives
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 FixatorExternal Fixator
A device placed outside A device placed outside the skin that stabilizes the skin that stabilizes bone fragments with pins bone fragments with pins or wires connected to barsor wires connected to bars
““Relative stability “Relative stability “Healing with callusHealing with callus
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External FixationExternal FixationAdvantagesAdvantages
Minimal damage to blood supply Minimal damage to blood supply Minimal damage to soft tissuesMinimal damage to soft tissuesFixation is away from site of injuryFixation is away from site of injuryGood option when significant infection riskGood option when significant infection risk
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External FixationExternal FixationDisadvantagesDisadvantages
Restricted joint motionRestricted joint motionPin tract infectionPin tract infectionCumbersome Cumbersome Inadequate stability for certain fracturesInadequate stability for certain fractures
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IndicationsIndicationsMost commonly used: Most commonly used:
– TibiaTibia– Distal radiusDistal radius
Less commonly used:Less commonly used:– FemurFemur– Humerus Humerus – Forearm Forearm
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IndicationsIndicationsOpen fracturesOpen fracturesClosed fractures with soft tissue Closed fractures with soft tissue
compromisecompromisePeriarticular fracturesPeriarticular fracturesPolytrauma/Damage controlPolytrauma/Damage controlPelvic fracturesPelvic fracturesChildren’s fracturesChildren’s fractures
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Open FracturesOpen FracturesAvoids injury siteAvoids injury siteAvoids additional injury Avoids additional injury
to soft tissues and to soft tissues and vascularity vascularity
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Open FracturesOpen Fractures
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Open FracturesOpen Fractures
Segmental bone lossSegmental bone loss
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Open FracturesOpen Fractures
Fractures needing nerve or Fractures needing nerve or vessel repairvessel repair
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Closed Fractures with Soft Closed Fractures with Soft Tissue CompromiseTissue Compromise
SwellingSwellingFracture blisters Fracture blisters
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Closed Fractures with Soft Closed Fractures with Soft Tissue CompromiseTissue Compromise
Crush injuriesCrush injuriesBurnsBurns
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Closed Fractures with Soft Closed Fractures with Soft Tissue CompromiseTissue Compromise
Compartment syndromeCompartment syndrome
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Periarticular FracturesPeriarticular Fractures
Severe fractures with joint Severe fractures with joint involvement and shaft involvement and shaft extensionextension
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Periarticular FracturesPeriarticular Fractures
• Spanning ex-fix if axially unstableSpanning ex-fix if axially unstable
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Periarticular FracturesPeriarticular Fractures
Hybrid Fixator:Hybrid Fixator:– Thin wires near jointThin wires near joint– Pins (Schanz Screws) in shaftPins (Schanz Screws) in shaft
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Periarticular FracturesPeriarticular Fractures
Reduce and fix the joint surfaceReduce and fix the joint surfaceSpan the diaphyseal Span the diaphyseal
segment without segment without
disturbing soft tissuesdisturbing soft tissues
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Periarticular FracturesPeriarticular Fractures
External fixation can be External fixation can be combined with internal combined with internal fixationfixation
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PolytraumaPolytraumaTemporary stabilization of long bone Temporary stabilization of long bone
injuries in unstable patientinjuries in unstable patient– Minimally invasiveMinimally invasive– Decreases bleedingDecreases bleeding– Pain controlPain control– Nursing careNursing care– ““Damage control”Damage control”
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Pelvic FracturesPelvic FracturesTemporary stabilization for Temporary stabilization for
closed fracturesclosed fracturesControls hemorrhageControls hemorrhageDecreases clot shearDecreases clot shear
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Pelvic FracturesPelvic Fractures
Open pelvic fractures = “The lethal injury”Open pelvic fractures = “The lethal injury”
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Pelvic FracturesPelvic Fractures
Quick applicationQuick applicationOpen or percutaneous pin Open or percutaneous pin
insertioninsertionEasily removed for Easily removed for
definitive ORIFdefinitive ORIF
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Children’s FracturesChildren’s Fractures
Femoral fracturesFemoral fracturesOne alternative to weeks of One alternative to weeks of
skeletal tractionskeletal tractionUsed less with use of flexible Used less with use of flexible
nailsnails
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Children’s FracturesChildren’s Fractures
Pin placement must avoid Pin placement must avoid growth plategrowth plate
Watch for pin tract infectionWatch for pin tract infectionOccasional joint stiffnessOccasional joint stiffness
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External FixationExternal Fixation
Fixator construct will depend on treatment Fixator construct will depend on treatment strategy:strategy:– Emergency careEmergency care
– Provisional careProvisional care– Definitive careDefinitive care
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External Fixator ConstructsExternal Fixator Constructs
Uni-planeUni-planeBi-planeBi-planeMulti-planeMulti-planeRingRing
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• Uni-plane
• Bi-plane
• Multi-plane
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Uni-plane FixatorUni-plane FixatorSingle BarSingle Bar
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Uni-plane FixatorUni-plane Fixator“Z Frame”“Z Frame”
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Uni-plane FixatorUni-plane FixatorDouble StackedDouble Stacked
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Bi-plane FixatorBi-plane Fixator
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Multi-plane FixatorMulti-plane Fixator
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Spanning External FixationSpanning 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
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Spanning Ex Fix
Adjunct to Internal FixationAdjunct to Internal Fixation– TemporaryTemporary– DefinitiveDefinitive
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Increase StabilityIncrease StabilityPinsPins
– Larger diameterLarger diameter– More pins More pins – Closer to fracture siteCloser to fracture site
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Increase StabilityIncrease Stability
Bars:Bars:– Closer to limbCloser to limb– More barsMore bars– Second plane at right Second plane at right
angle to decrease torsion angle to decrease torsion (twisting)(twisting)
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Increase StabilityIncrease Stability
Rings:Rings:– Smaller is stifferSmaller is stiffer
Use smallest diamaeter ring Use smallest diamaeter ring possible but allow for swellingpossible but allow for swelling
– More rings = more stableMore rings = more stable
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External Fixation AnatomyExternal Fixation Anatomy
Safe pin placementSafe pin placement““Safe corridors” Safe corridors” Know your anatomy to Know your anatomy to
safely place pins!safely place pins!
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Intraop SetupIntraop SetupCircumferential prep of entire limbCircumferential prep of entire limbRadiolucent tableRadiolucent tableC-armC-arm
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Intraop SetupIntraop Setup
Associated proceduresAssociated procedures IrrigationIrrigationDebridementDebridement Internal FixationInternal FixationBone graftBone graft
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Intraop SetupIntraop SetupAdequate fixator componentsAdequate fixator componentsCannulated screwsCannulated screwsLarge/small fragment setsLarge/small fragment sets
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Intraop Technique
Keep bars close to bone but…Keep bars close to bone but… . . . allow access for soft tissue . . . allow access for soft tissue
carecare Allow for swellingAllow for swelling Can be re-adjusted as neededCan be re-adjusted as needed
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ComplicationsComplications
Neurovascular injuryNeurovascular injury Pin looseningPin loosening Pin tract infectionPin tract infection Joint stiffnessJoint stiffness MalalignmentMalalignment MalunionMalunion NonunionNonunion
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ComplicationsComplications
Pin tract infections:Pin tract infections:– Most common complicationMost common complication– Avoid fracture areaAvoid fracture area– Don’t “burn” bone – pre-drillDon’t “burn” bone – pre-drill– Insert pin completelyInsert pin completely– Release skinRelease skin
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ComplicationsComplications
Know where pins Know where pins are going!are going!
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THANK YOU!THANK YOU!