Principles of External Fixation

Roman Hayda, MD
Original Authors: Alvin Ong, MD & Roman Hayda, MD; March 2004;
New Author: Roman Hayda, MD; Revised July 2006

Overview

Indications
Advantages and disadvantages
Mechanics
Biology
Complications

Indications
Definitive fx care:
Open fractures
Peri-articular fractures
Pediatric fractures
Temporary fx care
Damage control
Long bone fracture
temporization

Pelvic ring injury

Periarticular fractures

Malunion/nonunion
Arthrodesis
Osteomyelitis
Limb
deformity/length
inequality
Congenital
Acquired

Advantages

Minimally invasive
Flexibility (build to fit)
Quick application
Complex 3-C humerus fx
Useful both as a temporizing or definitive
stabilization device
Reconstructive and salvage applications

Disadvantages
Mechanical

Distraction of fracture site

Inadequate immobilization
Pin-bone interface failure
Weight/bulk
Refracture (pediatric femur)

Biologic

May result in
malunion/nonunion,
loss of function

Infection (pin track)

May preclude conversion to internal fixation
Neurovascular injury
Tethering of muscle
Soft tissue contracture

Components of the Ex-fix

Pins
Clamps
Connecting rods

Pins
Principle: The pin is the critical link
between the bone and the frame
Pin diameter
Bending stiffness
proportional to r4
5mm pin 144% stiffer
than 4mm pin

< 1/3 dia

Pins
Various diameters, lengths,
and designs

2.5 mm pin
4 mm short thread pin
5 mm predrilled pin
6 mm tapered or conical pin
5 mm self-drilling and self tapping
pin
5 mm centrally threaded pin

Materials
Stainless steel
Titanium
More biocompatible
Less stiff

Pin Geometry
Blunt pins
- Straight
- Conical

Self Drilling and Tapping

Pin coatings
Recent development of various coatings
(Chlorohexidine, Silver, Hydroxyapatite)

Improve fixation to bone

Decrease infection

Moroni, JOT, 02
Animal study, HA pin 13X higher extraction torque vs
stainless and titanium and equal to insertion torque
Moroni, JBJS A, 05
0/50 pts pin infection in tx of pertrochanteric fx

Pin Insertion Technique

1.Incise skin
2.Spread soft tissues to
bone
3.Use sharp drill and
sleeve
4.Irrigate while drilling
5.Place appropriate pin
using sleeve

Avoid soft tissue damage and bone

thermal necrosis

Pin insertion
Self drilling pin
considerations
Short drill flutes
thermal necrosis
stripping of near
cortex with far cortex
contact
Quick insertion
Useful for short term
applications

vs.

Pin Length
Half Pins
single point of entry
Engage two cortices

Transfixation Pins
Bilateral, uniplanar fixation
lower stresses at pin bone
interface
Limited anatomic sites (nv
injury)
Traveling traction
Courtesy Matthew Camuso

Pin Diameter Guidelines

Femur 5 or 6 mm
Tibia 5 or 6 mm
Humerus 5 mm
Forearm 4 mm
Hand, Foot 3 mm

Slide courtesy Matthew Camuso

Clamps

Two general varieties:

Single pin to bar clamps
Multiple pin to bar clamps

Features:
Multi-planar adjustability
Open vs closed end

Principles
Must securely hold the
frame to the pin
Clamps placed closer to
bone increases the rigidity
of the entire fixator

Connecting Rods and/or Frames

Options:
materials:
Steel
Aluminum
Carbon fiber
Design
Simple rod
Articulated
Telescoping

Principle: increased diameter = increased rigidity and

strength
Principle: double stack = increased rigidity

Bars
Stainless vs Carbon
Fiber
Radiolucency
diameter = stiffness
15% more rigid carbon vs
stainless in loading to
failure
frames with carbon fiber
are only 85% as stiff
limited by clamp tightening

Added bar stiffness

increased frame stiffness

Kowalski, M et al, Comparative Biomechanical Evaluation of Different External Fixator Sidebars:

Stainless-Steel Tubes versus Carbon Fiber Bars, JOT 10(7): 470-475, 1996

Ring Fixators
Components:
High tension thin wires
olive or straight
Wire and half pin clamps
Rings
Rods
Motors and hinges (not
pictured)

Ring Fixators
Principles:
Multiple tensioned thin wires (90130 kg)

Place wires as close to 90 to

each other
o

Half pins also effective

Use full rings (more difficult to
deform)

Can maintain purchase in

metaphyseal bone
Allows dynamic axial
loading
May allow joint motion

Multiplanar Adjustable Ring

Fixators
Application with wire or half pins
Adjustable with 6 degrees of freedom
Deformity correction
acute or over time

3A+ tibia with bone loss

Following frame adjustment and bone

grafting

Frame Types
Uniplanar
Unilateral
Bilateral
Pin transfixes extremity

Biplanar
Unilateral
Bilateral

Circular (Ring
Fixator)
Half-pins vs. transfixion
wires

Hybrid
Combines rings with planar
frames

Unilateral uniplanar Unilateral biplanar

Hybrid Fixators
Combines the
advantages of ring
fixators in periarticular
areas with simplicity
of planar half pin
fixators in diaphyseal
bone

From Rockwood and Greens, 5th Ed

Biomechanical Comparison
Hybrid vs Ring Frames
Ring frames resist axial and bending
deformation better than any hybrid
modification
Adding 2nd proximal ring and anterior half
pin improves stability of hybrid frame
Clinical application: Use full ring fixator for fx
with bone defects or expected long frame time
Pugh et al, JOT, 99
Yilmaz et al, Clin Biomech, 2003
Roberts et al, JOT, 2003

Frame Types
Standard frame
Joint spanning frame:
Nonarticulated
Articulated frame

Distraction or Correction frame

Standard Frame
Standard Frame
Design
Diaphyseal region
Allows adjacent
joint motion
Stable

Joint Spanning Frame

Joint Spanning Frame
Indications:
Peri-articular fx
Definitive fixation through
ligamentotaxis
Temporizing
Place pins away from
possible ORIF incision sites

Arthrodesis
Stabilization of limb with
severe ligamentous/vascular
injury: Damage control

Articulated Frame
Articulating Frame
Limited indications
Intra- and peri-articular fractures or ligamentous
injury
Most commonly used in the ankle, elbow and
wrist
Allows joint motion
Requires precise placement in the axis of joint motion

(Figure from: Rockwood and Green, Fractures in Adults, 4th ed, Lippincott-Raven, 1996)

Correction of Deformity or Defects

May use unilateral or ring frames
Simple deformities may use simple frames
Complex deformities require more complex
frames
All require careful planning

3B tibia with segmental bone loss, 3A

plateau, temporary spanning ex fix

Convert to circular
frame, orif plateau
Corticotomy and
distraction

Consolidation
*note: docking site bone grafted

EXTERNAL FIXATION
Biomechanics

Leave the Eiffel tower in Paris unless you intend to gratify your rep!

Understand fixator mechanics

do not over or underbuild frame!

Fixator Mechanics:
Pin Factors
Larger pin diameter
Increased pin spread
on the same side of the fracture

Increased number of pins

(both in and out of plane
of construct)

Fixator Mechanics:
Pin Factors
Oblique fxs subject to
shear
Use oblique pin to
counter these effects

Metcalfe et al, JBJS B, 2005

Lowenberg et al, in press

Fixator Mechanics: Rod Factors

Frames placed in the same plane as the applied load
Decreased distance from bars to bone
Double-stacking of bars

Frame Mechanics:
Biplanar Construct
Linkage between frames in
perpendicular planes (DELTA)

Frame Mechanics: Ring Fixators

Spread wires to as
close to 90o as
anatomically
possible
Use at least 2 planes
of wires/half pins in
each major bone
segment

Modes of Fixation
Compression

Sufficient bone stock

Enhances stability
Intimate contact of bony ends
Typically used in arthrodesis or to complete union of a fracture

Neutralization
Comminution or bone loss present
Maintains length and alignment
Resists external deforming forces

Distraction
Reduction through ligamentotaxis
Temporizing device
Distraction osteogenesis

Biology
Fracture healing by stable
yet less rigid systems
Dynamization
Micromotion

micromotion
formation
Kenwright, CORR, 1998
Larson, CORR, 2001

callus

(Figures from: Rockwood and Green,

Fractures in Adults, 4th ed,
Lippincott-Raven, 1996)

Biology
Dynamization = loadsharing construct that
promote micromotion at
the fracture site
Controlled load-sharing
helps to "work harden" the
fracture callus and
accelerate remodeling

(Figures from: Rockwood and Green,

Fractures in Adults, 4th ed,
Lippincott-Raven, 1996)

Kenwright and Richardson, JBJS-B, 91

Quicker union less refracture
Marsh and Nepola, 91
96% union at 24.6 wks

Anatomic Considerations
Fundamental knowledge of the anatomy is critical
Avoidance of major nerves,vessels and organs
(pelvis) is mandatory
Avoid joints and joint capsules
Proximal tibial pins should be placed 14 mm distal to articular
surface to avoid capsular reflection

Minimize muscle/tendon impalement (especially

those with large excursions)

Lower Extremity safe sites

14 mm

Avoid
Nerves
Vessels
Joint capsules

Minimize
Muscle transfixion

Upper Extremity Safe Sites

Humerus: narrow lanes

Proximal: axillary n
Mid: radial nerve
Distal: radial, median and ulnar n
Dissect to bone, Use sleeves

Ulna: safe subcutaneous border, avoid

overpenetration
Radius: narrow lanes
Proximal: avoid because radial n and PIN, thick muscle sleeve
Mid and distal: use dissection to avoid sup. radial n.

Damage Control and Temporary

Frames
Initial frame application rapid
Enough to stabilize but is not
definitive frame!
Be aware of definitive
fixation options
Avoid pins in surgical approach sites

Depending on clinical
situation may consider
minimal fixation of articular
surface at initial surgery

Conversion to Internal Fixation

Generally safe within 2-3 wks
Bhnadari, JOT, 2005
Meta analysis: 6 femur, 9 tibia, all but one retrospective
Infection in tibia and femur <4%

Rods or plates appropriate

Use with caution with signs of pin irritation
Consider staged procedure
Remove and curette sites
Return following healing for definitive fixation
Extreme caution with established pin track infection
Maurer, 89
77% deep infection with h/o pin infection

Evidence
Femur fx
Nowotarski, JBJS-A, 00
59 fx (19 open), 54 pts,
Convert at 7 days (1-49 days)
1 infected nonunion, 1 aseptic
nonunion
Scalea, J Trauma, 00
Bilat open femur, massive
43 ex-fix then nailed vs 284
compartment syndrome, ex fix
primary IM nail
then nail
ISS 26.8 vs 16.8
Fluids 11.9l vs 6.2l first 24
hrs
OR time cc 35 min EBL 90cc
vs 135 min EBL 400cc
Ex fix group 1 infected
nonunion, 1 aseptic nonunion

Evidence
Pilon fx
Sirkin et al, JOT, 1999

49 fxs, 22 open
plating @ 12-14 days,
5 minor wound problems, 1 osteomyelitis
Patterson & Cole, JOT, 1999

22 fxs
plating @ 24 d (15-49)
no wound healing problems
1 malunion, 1 nonunion

Complications

Pin-track infection/loosening
Frame or Pin/Wire Failure
Malunion
Non-union
Soft-tissue impalement
Compartment syndrome

Pin-track Infection
Most common
complication
0 14.2% incidence
4 stages:
Stage I: Seropurulent
Drainage
Stage II: Superficial
Cellulitis
Stage III: Deep Infection
Stage IV: Osteomyelitis

Pin-track Infection
Union Fx infection Malunion Pin Infection

Mendes, 81

100%

4%

NA

Velazco, 83

92%

NA

5%

12.5%

Behrens, 86

100%

4%

1.3%

6.9%

Steinfeld, 88

97%

7.1%

23%

0.5%

Marsh, 91

95%

5%

5%

10%

Melendez, 89

98%

22%

2%

14.2%

Pin-track Infection
Prevention:
Proper pin/wire insertion technique:
Subcutaneous bone borders
Away from zone of injury
Adequate skin incision
Cannulae to prevent soft tissue injury
during insertion
Sharp drill bits and irrigation to
prevent thermal necrosis
Manual pin insertion
(Figures from: Rockwood and
Green, Fractures in Adults, 4th ed,
Lippincott-Raven, 1996)

Pin-track Infection
Postoperative care:
Clean implant/skin
interface
Saline
Gauze
Shower

Pin-track Infection
Treatment:

Stage I: aggressive pin-site care and oral cephalosporin

Stage II: same as Stage I and +/- Parenteral Abx
Stage III: Removal/exchange of pin plus Parenteral Abx
Stage IV: same as Stage III, culture pin site for
offending organism, specific IV Abx for 10 to 14 days,
surgical debridement of pin site

Pin Loosening
Factors influencing Pin
Loosening:

Pin track infection/osteomyelitis

Thermonecrosis
Delayed union or non-union
Bending Pre-load

Pin Loosening
Prevention:

Proper pin/wire insertion techniques

Radial preload
Euthermic pin insertion
Adequate soft-tissue release
Bone graft early
Pin coatings

Treatment:
Replace/remove loose pin

Frame Failure
Incidence: Rare
Theoretically can occur with recycling of
old frames
However, no proof that frames can not be
re-used

Malunion
Intra-operative causes:
Due to poor technique

Prevention:

Clear pre-operative planning

Prep contralateral limb for comparison
Use fluoroscopic and/or intra-operative films
Adequate construct

Treatment:
Early: Correct deformity and adjust or re-apply frame prior to
bony union
Late: Reconstructive correction of malunion

Malunion
Post-operative causes:
Due to frame failure

Prevention:
Proper follow-up with both clinical and radiographic
check-ups
Adherence to appropriate weight-bearing restrictions
Check and re-tighten frame at periodic intervals

Treatment:
Osteotomy/reconstruction

Non-union
Union rates comparable to those achieved with
internal fixation devices
Minimized by:

Avoiding distraction at fracture site

Early bone grafting
Stable/rigid construct
Good surgical technique
Control infections
Early wt bearing
Progressive dynamization

Soft-tissue Impalement
Tethering of soft tissues can result in:
Loss of motion
Scarring
Vessel injury

Prevention:

Check ROM intra-operatively

Avoid piercing muscle or tendons
Position joint in NEUTRAL
Early stretching and ROM exercises

Compartment Syndrome
Rare
Cause:
Injury related
pin or wire causing intracompartmental bleeding

Prevention:
Clear understanding of the anatomy
Good technique
Post-operative vigilance

Future Areas of Development

Pin coatings/sleeves
Reduce infection
Reduce pin loosening

Optimization of dynamization for fracture

healing
Increasing ease of use/reduced cost

Construct Tips

Chose optimal pin diameter

Use good insertion technique
Place clamps and frames close to skin
Frame in plane of deforming forces
Double stack frame

Plan ahead!

Summary
Multiple applications
Choose components and geometry suitable
for particular application
Appropriate use can lead to excellent results
Recognize and correct complications early
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