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7.

MUSCULOSKELETAL TRAUMA
Basic Technique of External Fixation
Nurahmat Lubis, MD
Istan Irmansyah Irsan, MD

DEFINITIVE SURGICAL TRAUMA COURSE


KOLEGIUM ILMU BEDAH INDONESIA
2015
Basic Motor Skills
External Fixation
Indications & Biomechanics
External Fixation

Operative technique for bony realignment and


stabilization in trauma and reconstruction

Fractures
Limb deformity correction
Arthrodesis
Indications
Trauma
Open Fractures
Severe soft tissue injury
Comminution
Bone loss

Temporizing or Definitive
means of fixation
Indications

Deformity Correction

Congenital
Post-traumatic
Acquired
Indications

Reconstruction

Arthrodesis
Malunion
Nonunion
Infection
External Fixation

Constructs use pins and/or wires connected by


clamps to bars and/or rings

Constructs used to apply compression,


distraction or neutral forces on bone
External Fixation Constructs

Uniplanar

Biplanar

Circular (Ilizarov)

Hybrid
Advantages

• Simplicity and ease of application

• Minimal blood loss

• Adjustability after surgery

• Access for wound management


Disadvantages
• Anatomic structures at risk (Safe Zones)

• Pin/Wire site infections

• Joint contractures

• Prolonged time to bony healing


Safety Factors

Pin/Wire should not


be in the fracture

When drilling go slow as


not to burn the bone

Don’t put pin at the


wound
Stability Factors

Pin/Wire Location

Maximal pin span


Stability Factors

Pin/Wire Number

More pins distribute


forces and increase
construct stiffness
Stability Factors

Pin/Wire Size
Torsional strength
proportional to its radius4

Pin core diameter


<
1/3 bone diameter
Stability Factors
Insertion Technique

Thread-Shank junction
is weakest point

Insert pin shank to


proximal cortex
(2x increased stiffness)
(threads = bone width)

Off plane pin insertion


Stability Factors
Insertion Technique
Circular frames

Wires placed at 90o stiffer


than at 45o

Increased wire tension


stiffens circular frames
Stability Factors

Pre-drilling

Low-speed drilling reduces


thermal necrosis

HA coating increases
pullout strength
Carbon Fiber Rods

Carbon fiber rods stiffer than steel tubes

Lightweight

Radiolucent
Stability Factors
Lower Bone-Rod distance
increases stiffness

In-line stacking
increases stiffness

Second sidebar at 90o to


first increases stiffness
Spanning External Fixators

Portable Traction

Span intra-articular
fracture

Aide reduction through


ligamentotaxis
Compression External Fixators

Arthrodesis in the
setting of infection
Distraction External Fixators

Limb Lengthening
through
Distraction Osteogenesis

1mm / day

Multiplanar corrections
Damage Control and Temporary
Frames
Pins
Pin Geometry
Lower Extremity “safe” sites

• Avoid
– Nerves
– Vessels
– Joint capsules
• Minimize
– Muscle transfixion
Pin Insertion Technique

Incise skin
Spread soft tissues to bone
Use sharp drill with sleeve
Irrigate while drilling
Place appropriate pin using sleeve
Pin insertion
Clamps
Connecting Rods and/or Frames
Pin-track Infection
Union Fx infection Malunion Pin Infection
Mendes, ‘81 100% 4% NA 0

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, ’8 98% 22% 2% 14.2%


9
Pin-track Infection
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
Construct Tips
Chose optimal pin diameter
Use good insertion technique
Place clamps and frames close to skin
Frame in plane of deforming forces
Stack frame (2 bars)
Re-use/Recycle components (requires
certified inspection).
Summary

Multiple applications

Choose components and geometry suitable for


particular application

Appropriate use can lead to excellent result

Recognize and correct complications early


Leave the Eiffel tower in Paris!
BASIC PRINCIPLE OF
PLATING FOR SIMPLE
FRACTURE
BASIC PLATING PRINCIPLE FOR
SIMPLE FRACTURE

NOT FOR

Proximal and Distal part of the long


bones

Pathological fracture
BASIC PLATING PRINCIPLE FOR
SIMPLE FRACTURE

NOT FOR

Osteoporotic fracture

Complicated fracture
Reduction Techniques

• Over the last 25 years the biggest change


regarding ORIF of fractures has probably been
the increased respect for soft tissues.

• Whatever reduction or fixation technique is


chosen, the surgeon must minimize periosteal
stripping and soft tissue damage.
– EXAMPLE: supraperiosteal plating
techniques
Direct Reduction Technique
• Pointed reduction clamps used to reduce a complex distal femur
fracture
• Open surgical approach
• Excellent access to the fracture to place lag screws with the
clamp in place
• Remember, displaced articular fractures require direct exposure
and reduction because anatomic reduction is essential
Reduction Technique - Clamp and
Plate
• Place clamp over bone and the plate
• Maintain fracture reduction
• Ensure appropriate plate position
proximally and distally with
respect to the bone, adjacent joints, and
neurovascular structures
• Ensure that the clamp does not scratch the
plate, otherwise the
created stress riser will weaken the plate