external fixation indications and techniques · 2019. 1. 18. · pelvic fractures children’s...
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External Fixation Indications and Techniques
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ObjectivesIdentify 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 FixatorA 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
!Restricted joint motion Pin tract infection Cumbersome Inadequate stability for certain fractures
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IndicationsMost commonly used: ▪ Tibia ▪ Distal radius !
Less commonly used: ▪ Femur ▪ Humerus ▪ Forearm
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IndicationsOpen fractures Closed fractures with soft tissue compromise Periarticular fractures Polytrauma/Damage control Pelvic fractures Children’s fractures
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Open FracturesAvoids injury site
Avoids additional injury to soft tissues and vascularity
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Open Fractures
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Open FracturesSegmental 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 FracturesReduce 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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PolytraumaTemporary stabilization of long bone injuries in unstable patient ▪ Minimally invasive ▪ Decreases bleeding ▪ Pain control ▪ Nursing care ▪ “Damage control”
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Pelvic FracturesTemporary stabilization for closed fractures
Controls hemorrhage
Decreases clot shear
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Pelvic FracturesOpen pelvic fractures = “The lethal injury”
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Pelvic FracturesQuick application
Open or percutaneous pin insertion
Easily removed for definitive ORIF
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Children’s FracturesFemoral 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
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Spanning Ex Fix
Adjunct to Internal Fixation ▪ Temporary ▪ Definitive
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Increase StabilityPins ▪ 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 StabilityRings:
▪Smaller is stiffer ▪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 SetupCircumferential prep of entire limb
Radiolucent table
C-arm
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Intraop SetupAssociated procedures
Irrigation
Debridement Internal Fixation
Bone graft
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Intraop SetupAdequate 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!