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Ihab Badawe. Ext Fix Final

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Fathy Alhallag
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35 views

Ihab Badawe. Ext Fix Final

Uploaded by

Fathy Alhallag
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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External Fixation

Dr. Ihab Badawi


Professor of Orthopaedic surgery
Alexandria university
External fixation refers to a technique for
immobilization of osseous fragments by their
impalement with metallic pins that are stabilized
in a rigid external frame
History

Hippocrate 2400 ys ago


History
Malgaigne 1840 Roux modification

Metal pins
Metal bands
External wooden splint
Belt
History

Lambotte 1902
History
 After the 2nd world war
Improvements:
 Increase stability
 Improve tolerance
 Ease application
Classification
Pin fixators Ring fixators

Simple pin fixators Clamp pin fixators

Independent articulations connect


The pins of each fragment are held in a clamp
each pin with a longitudinal rod
which is connected to a longitudinal rod
Simple fixators
AO tubular fixator
Advantages :
 Each pin can be placed at the most desirable angle
 The distance between the pins can be freely chosen
 Sequential frame building down is possible
Disadvantages:
 Fracture fragments must be reduced before fixator
application
 Once applied fracture adjustment is not possible
Clamp fixators
Advantages:
 Fracture reduction is possible after application of the fixator.

Disadvantages:
 Size and shape of the clamps dictate pin placement and spread
 Pin exchange is possible only after clamp release
 Frame build down, sequential pin loosening is not possible
Ring fixators
 Gradual adjustment for length and angulation after
frame application.
 KW under tension create a mechanical environment
that may be favorable to fracture healing
 Allow functional weight bearing
Disadvantages:
 Wires pass through hazardous and unsafe zones,
m impalement, joint stiffness, n v injuries
Fixation pins
 Material : Stainless steel, Titanium
Ti (more inert, less rigid).
 Coating: Hydroxyapatite
 Size: 1.5-6mm
 Design: Pointed ends
Smooth, threaded
Self drilling, Self tapping
Ilizarov wires
Fixation frames
 1976
 ASIF tubular fixator
 Low weight

Adjustable clamp
Fixation frames
 Pinless fixator
 Clamps
 Attached to AO fixator
 Emergency cases
 ICU or ward
 Free medullary canal
 + IMN
Fixation frames
 Wagner external fixator
 High patient tolerability
 Inadequate stability in open fractures and segment loss
 Once applied, further fracture reduction is impossible
Fixation frames
 Orthofix
 Fracture reduction after frame application
Fixation frames
 Hidelberg
Fixation frames
 Hoffmann

Adjustable slider bars


Universal ball joints
Fixation frames
 Ilizarov
Taylor spatial frame
Biomechanics
Stability:
The ability of the fixator to maintain the necessary
mechanical configuration during treatment
 Optimal mechanical environment:
Soft tissue healing
Resistance to infection
Increses capillary invasion in the fracture site
Stability
Intrinsic Extrinsic
Provided by the fixator Provided by the bone
Restoring compression strength in absence
of interfragmental compression

 Restoring bone contact by shortening


 Interposing pressure resistant graft
 Adjunctive internal fixation
Restoring bone contact by shortening
Adjunctive internal fixation
Intrinsic stability of the fixator
 Number of pins
 Size of pins
 Pin length
 Pin material
 Pin placement
 Side bars number
 Distance from the limb to the side bar
 Double bar
 Frame configuration
Intrinsic stability
 Pin Size
 {Radius}4
 Most significant factor in frame stability
Intrinsic stability
 Number of Pins
Intrinsic stability
A
C

Third pin (C) out of plane

B
Intrinsic stability
 Bone-Frame Distance
Intrinsic stability
Pin spread
 Pins close to fracture as possible
 Pins spread far apart in each fragment
Intrinsic stability
Side bars

Side bar number


Intrinsic stability
Frame assembly

Unilateral Bilateral Unilateral Bilateral


uniplane uniplane biplane biplane
Unilateral frame prevents varus or valgus, the rod
provides resisteace to tension on one side only.

Bilateral frames are good in both directions


Unilateral configuration
More comfortable

Less muscle impalement

Less skin pin bone interface problems

Less neurovascular injuries

Less stability ( stable fractures)


Unilateral frame prevents varus or valgus, the rod
provides resisteace to tension on one side only.
Bilateral configuration

Better stability in varus-valgus direction

Better compression

Transfixion of muscles and more interface problems


Biplane configuration

Increase anteroposterior stability


Increase torsional stability
Pin – bone interface
 Pin Bending Preload
Pin – bone interface
 Pin Bending Preload

 Radial preload (predrill w/


drill < inner diameter or
tapered pin)
 may decrease loosening and
increase fixation
Biomechanics of External Fixation
 SUMMARY OF EXTERNAL FIXATOR STABILITY:
Increase stability by:
1] Increasing the pin diameter.
2] Increasing the number of pins.
3] Increasing the spread of the pins.
4] Multiplanar fixation.
5] Reducing the bone-frame distance.
6] Predrilling and cooling (reduces thermal necrosis).
7] Radially preload pins.
-----------------------------------------------------------------------------
Ring fixator stability
 Size of the ring
 Number of rings
 Unopposed length between the rings
 Type of wires
 Number of wires
 Wire crossing angle
Goals of treatment
 Lengthening frames
 Compression frames
 Neutralization frames
 Soft tissue frames
Lengthening frames
 Chondrodiastasis: slow controlled symmetric
epiphyseal distraction
 Hemichondrodiastasis: closed gradual contolled
asymmetric distraction of growth plate to correct
angular deformities in the epiphyseal or metaphyseal
regions in cases of shortening + deformity
 Distraction epiphysiolysis: faster rate of distraction
 Callotasis: slow controlled distraction of bony callus
after a subperiosteal metaphyseal osteotomy
Neutralization frame
To maintain reduction of fragments to facilitate soft
tissue healing.
2ry procedures are necessary to achieve consolidation
 Open fractures
 Exposed osseous defects
 Infected nonunion
 Osteomyelitis
After 2nd look debridement and partial closure
2 ws later
Exposed osseous defects
 Restoration of soft tissue envelope followed by osseous
stabilization+/- bone graft
 Bone transport
Bone transport
 Bone regenerate of the same size
 Avoids problems of bone grafts
Infected nonunion and osteomyelitis

 Debridement of infected bones and soft tissues,


followed by delayed bone grafting
 Compression distraction
 Bone segment transport
Tibial wound
Tibial wound

Release
incision
Compression frames
Definitive fracture treatment
Arthrodesis
Nonunion
Definitive fracture management
 Anticipated flap necrosis
 Open fractures
 Burns
 Periarticular fractures
 Vs ORIF:
Maintain functional status
Axial micromovements
less skin complications
Less tolerated
Anticipated flap necrosis
Open fractures
Peri articular fractures
Truck driver
Calcaneal fr
Old malunited
fracture femur
shortening
Small wound at presentation led to
Osteotomies
Compression frames
Arthrodesis
Compression frames
Uninfected nonunions
Bad skin condition
Soft tissue frames
Foot deformities
Knee flexion contracture
Severe wrist contracture
ROM
10 ws removal of the rods
1 week
after
frame
removal
Complications
Pin tract infection
Grade I: serous discharge
Grade II: superficial cellulitis
Grade III: deep infection
Grade IV: osteomyelitis
Prevention of pin tract infection
 Adequate fixator stability
 Prestressing of the pins
 Adequate wire tensioning
 Decreasing thermal damage: predrilling & cooling
 Adequate pin incisions
 Building the frame to the wires
 Threaded portion of the pins must not be evident
 Adequate pin care
Pin tract infection
Pin loosening and breakage
Limitation of joint motion
Muscle contractures
Joint luxation
Neurovascular injuries
Delayed union and nonunion
Premature consolidation

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