external fixator

1. 1

2. “External Fixator is a device uses for
stabilization and immobilization of long
bone open fractures.”
2

3. History

Earliest recognizable
External fixations by
Malgaigne 1840 pin
for tibial fractures,
griffe for patella
3

4. History

Keetley 1893, Ollier,
Roux
4

5. History

Parkhill 1894 Threaded
pins and clamp
5

6. History

Lambotte 1902, self tapping threaded pins, rod,
adjustable clamps
6

7. History

In 1917. Humphry is the 1st man who uses threaded pins,
but he uses only one pin above fracture and one below
the fracture site.

In 1948, Charnley popularized his compression device to
facilitate arthrodesis of joints.
7

8. History


In 1966 and 1974,Anderson et al. uses transfixing pins
incorporated into a plaster cast for management of
large series of tibial shaft fractures .
From 1968 to 1970 Vidal and Vidal et al. modified
original Hoffmann device from a single half –pin unit to a
quadrilateral bicortical frame , greatly increasing rigidity.
8

9. 9

10. Types



Type -1 Unilateral Uniplanar
Type -2 Uniplanar Bilateral.
Type -3
◦ Classical Bilateral Biplanar.
◦ Delta Unilateral Biplanar

According to Planes:
◦ Planner: Hoffman’s, orthofix etc.
◦ Circular: Ilizarov
10

11. 11

12. 12

13. For periarticuler fracture
 Thin wire and ring near joint
 Schanz pin in shaft

13

14. 
Intrinsic
stability of frame (S)
EX I
S = ----------L
E=modulus of elasticity =constant
I= moment of intertia= constant
L= distance of frame from axis.
14

15. Biomechanics

Thus Stability is inversely proportional to the distance of
the assembly from the bone

(closer the frame to bone -more stable assembly)
15

16. To increase stability of bone –pin interface
1. Adequate no. of pins in each fragments
( 2 for most bone & 3 for femur)
2. Increase pin pitch (3.5mm)
3. Increase size of pin
16

17. Basic Components
A. Schanz Pin
4. 5mm short threaded for diaphysis
5/6 mm long threaded for metaphysis
B. Clamps
1) Universal Clamps
11) Open ended clamps
111) Transverse pin adjusting clamps
1v) Tube to tube clamps.
C. Tubes 11mm
17

18. Basic Components
18

19. Required instruments

Drill : Hand Drill

Drill bits – Long drill bits( 200mm) 3.5 and 4.5 mm
diameter.

Triple guide assembly , consist of trocar(3.5mm), inner
Sleeve and outer sleeve

T Handle for insertion of the Schanz pin.
19

20. Required instruments
20

21. 
21

22. 
22

23. Indications
severe open fractures (Gustilo 3b,3c)
closed fractures with severe soft-tissue injury or severely
comminuted fractures or floating knee #
open fractures involving bone loss
compartment syndrome after fasciotomy
adjunct to internal fixation
limb lengthening or bone transport
fracture associated with severe burn
Arthrodesis
Infected fractures or nonunions
Correction of malunions
Fixation after radical tumor excision with autograft or allograft
23

24. External fixator as temporary device



Soft tissue healed
If the soft-tissue injuries
have healed satisfactorily
within 2 weeks without pin
track infection, the external
fixation can be removed.
It is then replaced by
internal fixation with either
a plate or a nail.
24

25. External fixator as temporary device
Soft-tissue problems persist
 Remove the external fixator
 Temporarily stabilize in cast
 Let pin track infection heal


If there is pin track infection, using a nail (especially with
reaming technique) can lead to intramedullary infection.
In this case plate osteosynthesis is clearly preferable.
25

26. External fixation as final fixation
In the event that soft-tissue
healing is not satisfactory after
4-6 weeks, and there is no pin
track infection, the external
fixator can be left on until the
fracture has healed.
In children fracture healing is
often completed within a period
of approximately 6-8 weeks.
26

27. External fixation as final fixation
27

28. Advantages

Less damage to blood supply of bone

Minimal interference with soft-tissue cover

Useful for stabilizing open fractures

Rigidity of fixation adjustable without surgery

Good option in situations with risk of infection
Requires less experience and surgical skill than
standard ORIF
Quite safe to use in cases of bone infection


28

29. Complications








Pin Track Infection.
Neurovascular Impalement.
Muscle or Tendon Impalement
Delayed Union.
Compartment Syndrome
Re-fracture
Limitation of further Alternatives.
Cosmetic Problem
29

30. IM nails vs External fixator
Henley (Clin. Orth., 1989) randomised study of
104 case II-IIIB tibial fractures by unreamed IM nail;
70 treated by external fixation.
Infection rates 7% IM nail, 11% external fixation.
There was no difference in time to union.
Follow up in 1998 (Journal Orth. Trauma.): “The severity
of soft tissue injury rather than the choice of implant
appears to be the predominant factor influencing
rapidity of bone healing and rate of infection”.
30

31. Site of insertion






Open fracture Tibia and Fibula
Open fracture Femur
Floating Knee
Open Fracture Humerus
Communited fracture distal Radius
Pelvic fracture.
31

32. Tibial Safe Zone
Proximal part of the proximal tibia
32

33. Tibial Safe Zone
Proximal 3rd distal to tibial tuberosity
33

34. Tibial Safe Zone
Mid Shaft
34

35. Tibial Safe Zone
Distal 3rd distal of tibial Shaft
35

36. Schanz pin insertion
36

37. Schanz Pin insertion for Metaphysis
37

38. 
After adequate skin incision Insert assembled triple
sleeve and push onto bone.

Hold the sleeve steady and lightly tap the trocer on to
the bone surface in order to create the initial
impression. This prevents slipping of the drill bit during
drilling.
38

39. Technique of Applications

Remove the trocar, insert the long 3.5 drill bit through
inner sleeve and drill through both cortices.

Withdraw the drill bit along with inner sleeve. Insert 4.5
mm drill bit through the outer sleeve and over drill the
near cortex.
39

40. Technique of Applications

Place a 4.5 mm Schanz Pin onto the T-handle.
Introduce through the outer sleeve and insert into the
bone till the thread are securely engaged into the far
cortex.
40

41. Technique of Applications for metaphysis

Insert the triple sleeve through an adequate skin
incision and push onto bone.

Drill the both cortex bone with 3.5 mm drill bit.

Insert 5mm long threaded Schanz Pin with T-handle.
41

42. Application of external fixator

Place the most distal
Schanz Pin using the
standard technique.

Place a universal clamp
onto the schanz pin

Fix a 11mm tube in this
clamp, so that it is
posterior to the schanz
pin.
42

43. Application of external fixator…

Slide 3 Universal clamps
onto this tube.

Insert most proximal
schanz pin.

Reduction of bone.

Fix the proximal schanz
pin.
43

44. Application of external fixator…

Insert the 3rd 4th schanz
pin accordingly.

Connect frame with
another Tube.

Second tube is clamped
in “mirror image” fashion
after prestressing.
44

45. In the OT
45

46. In the OT
Open fracture Gustilo IIIB with Fixator
46

47. In the OT
Flap Coverage
47

48. Built as uni- and multi- plane constructs
 Areas prone to soft tissue problems

◦ Knee
◦ Ankle
◦ Open Fractures

When multiple injuries prevent
definitive fixation
48

49. Spanning ex- fix if axially unstable
49

50. External fixation can
be combined with
internal fixation
50

51. 
Temporary stabilization of long bone injuries in
unstable patient
◦
◦
◦
◦
◦
Minimally invasive
Decreases bleeding
Pain control
Nursing care
“Damage control”
51

52. Certain intraarticular fracture can be treated by
ex-fix using traction by fixator on the capsule and
ligamentous structure around the joint.
 This work well for comminuted intraarticular
fracture of the distal radius.

52

53. Temporary stabilization for closed fractures
 Controls hemorrhage
 Decreases clot shear
 Open pelvic fractures

53

54. Other External Fixators

Ilizarov External Fixator.

Universal Mini external Fixator.

Modular external Fixator
54

55. Ilizarov External Fixator.
55

56. Ilizarov External Fixator.
56

57. Ilizarov External Fixator.
57

58. 

Micro-motion at fracture Site.
It is bi-lateral

More lighter than traditional External Fixator.

More ligamentotasis

Less chance of pin tract infections.
58

59. 59

60. 

The modular external fixator allows the
surgeon to reduce the fracture by
manipulation and to hold the reduction.
Free pin placement allows the surgeon:
◦ to spread both pins, thereby increasing
frame stiffness,
◦ to position pins according to the fracture
pattern or soft-tissue injury,
◦ to avoid injury to nerves or vessels.
60

61. 61

62. Hoffman II external fixation system
Synthes Tibial exfix Adjustable
62

63. 
External Fixator is a good device for the management of
open and complicated fractures.

Surgeon must have knowledge about neurovascular
plane of the involved Organ.

Skill for applying the fixator.
63

64. Campbell’s
operative orthopedics
Wheeless'
Textbook of Orthopaedics
http://www.wheelessonline.com/ortho
Synthes:
leading global medical device company.
http://us.synthes.com/
AO
Foundation. <www.aofoundation.com>
64

65. Thank You
65