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“External Fixator is a device uses for

stabilization and immobilization of long
bone open fractures.”

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History

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

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 History

 Keetley 1893, Ollier,

Roux

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 History

 Parkhill 1894 Threaded

pins and clamp

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 History

 Lambotte 1902, self tapping threaded pins, rod,

adjustable clamps

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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.

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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.

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9
 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

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

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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.

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 Biomechanics

 Thus Stability is inversely proportional to the distance of

the assembly from the bone

(closer the frame to bone -more stable assembly)

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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

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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

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Basic Components

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 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.

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Required instruments

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

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

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 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

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 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.

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 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.

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 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.

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External fixation as final fixation

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 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

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

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 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”.

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

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Tibial Safe Zone

Proximal part of the proximal tibia

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Tibial Safe Zone

Proximal 3rd distal to tibial tuberosity

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Tibial Safe Zone

Mid Shaft

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Tibial Safe Zone

Distal 3rd distal of tibial Shaft

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Schanz pin insertion

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Schanz Pin insertion for Metaphysis

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 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.

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 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.

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 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.

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 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.

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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.

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 Application of external fixator…
 Slide 3 Universal clamps
onto this tube.

 Insert most proximal

schanz pin.

 Reduction of bone.

 Fix the proximal schanz

pin.

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 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.

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In the OT

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In the OT

Open fracture Gustilo IIIB with Fixator

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In the OT

Flap Coverage

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 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 if axially unstable

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External fixation can
be combined with
internal fixation

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

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 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.

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

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 Other External Fixators
 Ilizarov External Fixator.

 Universal Mini external Fixator.

 Modular external Fixator

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Ilizarov External Fixator.

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Ilizarov External Fixator.

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Ilizarov External Fixator.

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

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 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.

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61
 Hoffman II external fixation system
Synthes Tibial exfix Adjustable

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 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.

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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>

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Thank You

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