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Selected
Instructional
Course Lectures
The American Academy of Orthopaedic Surgeons
PAUL J. D UWELIUS
EDITOR, VOL. 57

C OMMITTEE
PAUL J. D UWELIUS
CHAIRMAN
FREDERICK M. A ZAR
KENNETH A. E GOL
J. L AWRENCE M ARSH
M ARY I. O’C ONNOR

E X -O FFICIO
D EMPSEY S. S PRINGFIELD
DEPUTY EDITOR OF THE JOURNAL OF B ONE AND JOINT SURGERY
FOR INSTRUCTIONAL COURSE LECTURES
J AMES D. H ECKMAN
EDITOR-IN-CHIEF,
THE JOURNAL OF BONE AND JOINT SURGERY

Printed with permission of the American Academy of

Orthopaedic Surgeons. This article, as well as other lectures
presented at the Academy’s Annual Meeting, will be available
in March 2008 in Instructional Course Lectures, Volume 57.
The complete volume can be ordered online at www.aaos.org,
or by calling 800-626-6726 (8 A.M.-5 P.M., Central time).
Ziran_ICL.fm Page 1620 Friday, June 8, 2007 1:56 PM

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THE JOURNAL OF BONE & JOINT SURGER Y · JBJS.ORG E X T E R N A L F I X A T I O N : H OW TO M A KE I T WO R K
VO L U M E 89-A · N U M B E R 7 · J U L Y 2007

External Fixation: How to Make It Work

By Bruce H. Ziran, MD, Wade R. Smith, MD, Jeff O. Anglen, MD, and Paul Tornetta III, MD
An Instructional Course Lecture, American Academy of Orthopaedic Surgeons

The external fixator has been in use
for more than a century. The first use
was recorded by Carl Wilhelm Wutzer
(1789-1863), who employed pins and
an interconnecting rod-and-clamp
system. Parkhill (1897) and Lambotte
(1900) used devices that were unilateral
with four pins and a bar-clamp system.
By 1960, Vidal and Hoffmann had popu-
larized the use of an external fixator to
treat open fractures and infected pseud-
arthroses. The problems encountered
with external fixation in the late twenti-
eth century were predominantly due to
a lack of understanding of the princi-
ples of application, the principles of
fracture-healing with external fixation,
and the use of old technology. Its use
was reserved for the most severe inju-
ries and for cases complicated by infec-
tion. Thus, pin problems, nonunions,
and malunions were common. Since
Look for this and other related articles in Instructional Course Lectures,
Volume 57, which will be published by the American Academy of Ortho-
paedic Surgeons in March 2008:
• “Fractures of the Hip,” by Jeffrey C. Anglen, MD, and Michael
Baumgaertner, MD
then, better technology and under-
standing have allowed for greater
versatility and better outcomes. Si-
multaneous with developments in the
Western world, Ilizarov developed the
principles of external fixation with use
of ring-and-wire fixation. It was not
until the late 1980s and early 1990s,
when more interaction and exchange
between the West and East (Russia) was
possible, and with the help of Italians
who embraced the philosophy of exter-
nal fixation, that the use of external
fixation was proven to be successful.
Several variations of external fixation
have been developed, and its use is
now widespread. Unfortunately, in the
United States, all but a minority of sur-
geons still have substantial apprehen-
sion about the use of external fixation.
The goals of this Instructional
Course Lecture are to (1) review the
principles of external fixation and de-
scribe healing under these conditions;
(2) review existing technology with spe-
cific attention to pin design, modular
designs, and aspects of ring fixation for
the general practitioner; (3) outline the
paradigm of using the external fixator
for bone-healing; (4) discuss different
types of external fixator applications,
including damage-control frames and
configurations of hybrid frames for the
tibia; and (5) review pin-care issues and
present pin-care techniques that work.
Principles of
External Fixation
External fixation is a minimally inva-
sive technique whose application and
management have been refined so that
it is now another valuable tool in the
management of fractures and other
complicated musculoskeletal condi-
tions. From pin care to frame mechan-
ics, the fixator can be applied and
adjusted to meet the needs in each clini-
cal context, and many of the problems
previously associated with its use can be
circumvented. Even so, it is not a pana-
cea and should not be used in situations
in which plates or nails are more suit-
able. Currently the external fixator has

Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. One or more of the
authors, or a member of his or her immediate family, received, in any one year, payments or other benefits in excess of $10,000 or a commitment
or agreement to provide such benefits from commercial entities (Synthes and Stryker). No commercial entity paid or directed, or agreed to pay or di-
rect, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the au-
thors, or a member of their immediate families, are affiliated or associated.

J Bone Joint Surg Am. 2007;89:1620-32

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two common treatment configura-
tions: the damage-control orthopaedic
frame, which was designed to be a
temporary device, and the definitive-
treatment frame, which was designed
to be used for definitive management of
fractures and for posttraumatic recon-
struction. These two applications are
based on different principles of treat-
ment. When the damage-control frame
is used, the impact of the fixator on the
systemic state of the patient and on the
definitive intervention that may follow
(e.g., plate or nail fixation) must be
considered. Also, it may become neces-
sary to use the external fixator as the
definitive treatment, so it is important
to know how to convert the damage-
control frame to the definitive-treatment-
frame configuration. When the defini-
tive-treatment-frame configuration is
used, it is critical to understand how to
modulate the mechanical properties of
the fixator in response to the bone be-
ing treated. Thus, an understanding of
how to “read the bone” is important, as
is an understanding of the techniques
of application that allow long-term
use of the fixator. Finally, since some
frames will need to be in place for a
prolonged period (e.g., those used for
limb-lengthening and salvage), effec-
tive management of routine issues
(pin tracks, discomfort, and walking)
is necessary.
Damage-Control Frames
The early damage-control frames were
used primarily for severe open fractures
because these fractures were not amena-
ble to the fracture fixation techniques
available at the time. Since external fixa-
tion was used in the most extreme cases,
it was associated with the most compli-
cations, such as infection and nonunion.
Furthermore, effective principles of soft-
tissue management and ways to obtain
healing in the presence of exposed bone
and bone loss were just being learned.
Nonetheless, for lack of a better option,
external fixation was used. As plate and
nail fixation methods improved, frac-
tures in most polytraumatized patients
were stabilized with definitive fixation
immediately (in less than twenty-four
to forty-eight hours). This has been de-
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E X T E R N A L F I X A T I O N : H OW
scribed as the era of early total care. We
subsequently learned that, while early
total care was reasonable for the bone,
it was not always optimal for every pa-
tient because of numerous systemic
issues. The evolution of collaborative
management of the trauma patient, for
whom orthopaedic treatment is carried
out within the context of the “big pic-
ture,” heralded the modern era of
damage-control orthopaedics. In this
era, there is appropriate stabilization of
the essential bone injuries (usually with
a damage-control orthopaedic frame),
until the patient’s systemic condition
becomes optimized, at which point de-
finitive fracture stabilization is under-
taken, usually with nails or plates. While
there remains controversy about the
timing of fixation, which is beyond the
scope of this lecture, a definitive indica-
tion has been established for external
fixation as a method with which to stabi-
lize the skeleton during the early stages
of polytrauma.
In this lecture, the application
of a damage-control orthopaedic
frame for the pelvis and extremities
will be described. Simple-to-remember
anatomic windows and simple frame
constructs that can be applied to most
fractures will be presented. With the
use of battery-powered drills, a single
“damage-control tray” can be assem-
bled to simplify application.
Definitive-Treatment Frames
When external fixation is used as defini-
tive treatment, it should first be applied
in a configuration that provides the
maximum stability (a rigid construct)
to the fresh fracture environment. This
is the best environment for healing of
the soft tissues as well as for the early
stages of bone-healing. However, this
environment should not be maintained
indefinitely because it will result in ex-
cessive stress-shielding of the fracture
site and can lead to an osteopenic non-
union. This type of nonunion is one of
the most challenging to treat since there
is not only a problem with healing, but
also challenges with regard to obtain-
ing a stable construct because of the
changes in bone quality. Over time, the
external fixator should be changed or
TO M A KE I T WO R K
modulated to allow a progressive load
transfer or destiffening of the construct
to help stimulate bone-healing.
Once there is evidence of bio-
logic activity (early fracture callus),
there should be a slow and progressive
load transfer to the healing callus. As
hypothesized by Pauwels1 and later ex-
plained in different terms by Perren2
(with his interfragmentary strain the-
ory), pure compression and hydrostatic
pressure will stimulate the mesenchymal
cells to differentiate toward chondro-
genesis and subsequently endochondral
ossification. Strain will result in the for-
mation of collagenous tissue and sub-
sequent intramembranous ossification.
Combinations of these two temporally
spaced events (compression then strain)
can manifest themselves as callus heal-
ing or, as is the case with use of the
Ilizarov principle, regenerate forma-
tion2. All of this, however, depends on
adequate blood flow because, in its ab-
sence, there will be no bone-healing, re-
gardless of the type of fracture fixation.
Thus, as the initial construct with the
stiff fixator begins to demonstrate some
biologic activity, the fixator undergoes
a “controlled destiffening” so that there
is a slow but definitive transfer of load-
bearing from the fixator to the bone.
This load-sharing will gradually stimu-
late the developing callus until solid
bone-healing has occurred.
Several authors have examined
both theoretical and practical methods
of analyzing healing in association with
the use of external fixation2-10. Factors
that contribute to the nature and speed
of osseous healing include the location
of the fracture, the nature of the blood
supply, and the method of fixation (pin
or wire configuration). While the expe-
rience has not been well documented
in the English-language literature, those
who have visited the center in Russia
established by Ilizarov have seen re-
markable work, all done with fine wire
fixation. Metaphyseal healing within
three to four weeks, massive reconstruc-
tions, and eradication of infection have
all been demonstrated (personal com-
munication). Again, as a result of the
historic geopolitical issues, such infor-
mation has not been well disseminated
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in the Western literature. What the
Russians have demonstrated clearly is
that appropriate concern regarding the
biology of the soft tissues as well as that
of the bone, along with stable frame
configurations and physiologic load-
ing, can result in reliable healing with
use of external fixation. Usually, frame
constructs start out stiff and progres-
sively transfer load to healing bone.
However, two crucial elements
are not well known: how to optimize
the load transfer (destiffening) and
how to know when it is complete and
the fracture has healed. Still, the goal of
external fixation is to provide what has
been called flexible stability. The stabil-
ity is provided by the frame and the con-
struct while the flexibility is added by
manipulating the components. Inciden-
tally, this is the same principle on which
modern plate-fixation techniques are
based. As constructs began to include
longer plate spans with fewer screws, the
introduction of locked plates essentially
resulted in an internalized fixator. Now
it is commonplace to use longer plate
spans with a few widely spaced locked
screws to obtain a flexible (long-span)
but stable (locked-screw) construct.
The ring fixator is based on the
same principles, in that initial stability
is achieved with multidirectional wires
or pins and little initial weight-bearing is
allowed to obtain a stable environment.
Then, as weight-bearing is initiated,
there is a controlled axial micromotion
that provides the stimulus for fracture-
healing. Since the device is inherently
flexible and yet stable, it achieves the
same end result. In fact, as tensioned
wires are loaded, they often loosen and
serendipitously transfer more load to
the construct. If this occurs too quickly,
the subsequent excessive instability will
result in pin-related problems and dis-
comfort; hence, the saying among expe-
rienced users of ring-and-wire fixators
has been: “A stable frame is a comfort-
able frame, and a comfortable frame is a
stable frame.”
Because use of ring and wire fix-
ators is complex, in this lecture, we will
only discuss the use of the simpler hy-
brid frame. With use of this frame, the
principles that should be followed in-
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E X T E R N A L F I X A T I O N : H OW
clude beginning with a rigid frame
construct. As the construct with the
stiff fixator begins to demonstrate some
biologic activity (fracture callus equals
evidence of vascularity), the fixator un-
dergoes a “controlled destiffening,” so
that there is a slow but definitive trans-
fer of load from the fixator to the bone
during weight-bearing activities. In the-
ory, this load-sharing gradually stimu-
lates the developing callus until healing
has occurred. If there is no evidence of
biologic activity or vascularity (i.e.,
no callus), an intervention such as
bone-grafting or resection and trans-
port should be considered. An atrophic
nonunion will not heal regardless of
the device that is used.
Pin Technology, Design, and
Method of Application
There are many different pin designs,
and there remains a philosophical rift
among surgeons with regard to the best
way to place pins. What we have learned
is that mechanical chipping and ther-
mal necrosis of the bone are deleterious
to pin longevity and that the most im-
portant factor may be the management
of the soft tissues around the pin. Older
pins were designed either to be placed
after predrilling or to be self-drilling
and threading. There are pros and cons
to both methods. With predrilling,
the cutting should be done with sharp,
well-designed drills, and the thermal
necrosis and mechanical issues are mini-
mized. (It is important for the surgeon
to check the drills to ensure a sharp bit.)
However, there is definitely a wobble
during the subsequent hand placement
of the pins. This wobble can result in a
small but meaningful conical deforma-
tion of the near cortex, which reduces
the initial stability of the pin in the near
cortex and increases the stress in the far
cortex. On the other hand, the older
spade-tipped pin (also called a trocar),
which was drilled directly into the bone,
resulted in chipping of the bone and suf-
ficient heat generation to cause necrosis
of the bone. Thus, their poor design de-
feated their advantage (except in meta-
physeal bone).
Subsequently, pin designs have in-
cluded a modified drill point with flutes
TO M A KE I T WO R K
along with threads with a cutting lead
edge for tapping, followed by threads
for fixation. This allows one-step place-
ment of pins that minimizes thermal
and mechanical complications. The pins
can be placed with a motorized device,
and the controlled axial motion of in-
sertion minimizes the wobble of hand
placement. Critics of one-step insertion
point to the difficulty in feeling the far
cortex as well as the theoretical possibil-
ity of stripping the near-cortex threads
when the cutting tip encounters the en-
dosteal surface of the far cortex. How-
ever, the use of appropriate cutting tips
as well as an appropriately designed
thread pitch allows the advancement
speed of the pin (determined by the
thread pitch) to be controlled such that
the pin engages and cuts through the far
cortex without problems. Furthermore,
as a result of the brief resistance of the
pin tip as it encounters the far cortex,
there is usually an audible and palpable
drain on the drill motor at such an in-
stant. This alerts the surgeon that the
far cortex has been reached so that over-
penetration can be avoided.
Such theoretical advantages were
demonstrated in a study of dogs by
Seitz et al., who found a 22% decrease
in the pull-out strength of self-drilling
pins placed with motorized power as
well as a substantial wobble with pins
placed by hand11. Since pull-out is rarely
a mode of failure and loose pins are a
frequent cause of pin and/or soft-tissue
problems, the potential downside of
wobble makes power insertion an at-
tractive option. The downside of power
insertion is mainly related to the use of
improper technique.
The issue of heat generation with
self-drilling pins was studied with ther-
mocouples used near each cortex and
measurement of heat generation dur-
ing several modes of pin insertion and
was determined to depend on numer-
ous factors12. In that study, comparison
of predrilling with hand insertion, hand
insertion of self-cutting pins, and power
insertion revealed no apparent differ-
ences among the three methods of
insertion. In fact, power insertion
appeared to generate less heat. The ob-
vious question is why would the place-
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Fig. 1
Representation of different types of fixator constructs. Left = modular half-pin; center = unibody, monolateral;
and right = hybrid.
ment of self-cutting, self-tapping pins
with power generate less heat than the
other methods? The most likely conclu-
sion would be that the time in contact
with bone causes frictional heat during
insertion. Thus, although power inser-
tion appears more aggressive, because it
involves less time of frictional contact
with the bone it theoretically creates less
heat. Modern self-drilling pins placed
with power have been in use clinically
for many years and have demonstrated
good performance. One compromise is
to predrill the holes with a sharp drill
and use power to place the pins to avoid
the wobble that can occur with manual
placement.
Since the late 1990s, we have
used battery-powered drills to place
self-drilling, self-tapping half-pins
(thus, there has been no hand inser-
tion or predrilling), but we have paid
diligent attention to soft-tissue care. It
is important to feel and listen to the
pins during insertion. Usually, there
is a brief delay as the drill point cuts
through the near cortex, after which
it steadily progresses. Then there is a
slight sensation of resistance and a
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E X T E R N A L F I X A T I O N : H OW
change in the drill-motor pitch when
the far cortex is reached. The advance
should be stopped at that point. If resis-
tance is encountered and excessive drill-
ing is required, something is wrong and
the pin may need to be repositioned.
Another recent advance has been
the use of pin coatings both to enhance
fixation and to reduce infection. Silver-
coated pins have been shown to be asso-
ciated with less bacterial colonization
than uncoated pins, but their clinical
performance has not been found to be
definitively superior to that of uncoated
pins. There is also a potential for sys-
temic silver absorption with their use13.
Hydroxyapatite-coated pins have had
an excellent track record with regard to
fixation and longevity and have outper-
formed standard titanium pins with re-
gard to both infection and longevity14.
Finally, tapered pins were developed to
increase radial preload and insertion
torque, both of which have been found
to improve pin longevity. However, if the
pins are backed up, even a slight amount,
their benefit is lost because of the taper,
and they need to be well monitored. As
a result of these issues as well as the suc-
TO M A KE I T WO R K
cessful performance of other designs,
the practical value of tapered pins is
questionable at this juncture.
Fixator Designs: Comparison
of Modular, All-in-One,
and Hybrid Designs
There are various designs of external fix-
ators. Outdated, single-bar devices had
difficulty in maintaining fracture align-
ment. The improved manufacturing
and design of clamps (such as those
made by Stryker, Synthes, or Smith and
Nephew) have led to newer modular
designs that are very user-friendly and
adaptable to a wide variety of clinical
scenarios. The modern so-called uni-
lateral alternatives, such as those with
multidirectional connections and clus-
tered pin clamps on each side (EBI and
Orthofix types), have had an equal
amount of success when used properly
and have even been expanded to be
more modular. We are not aware of any
study demonstrating clinical superior-
ity of any one design. We prefer modular
designs because they are light, are easy
to apply, and provide the maximal ver-
satility in most clinical situations. Their
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application will be outlined below.
The circular fixator has a long
history and was popularized by those
who followed Ilizarov’s philosophy.
Because of a long learning curve, main-
tenance problems, and other difficul-
ties, this device was accepted by only a
minority of orthopaedic surgeons. In
response, the hybrid frame was devel-
oped to provide some of the advantages
of the ring design with the ease of ap-
plication of standard fixators, particu-
larly for periarticular fractures. The
hybrid frame was initially popular and
then quickly went out of favor because
of high rates of complications and fail-
ures. If the literature is critically re-
viewed, it is apparent that most of the
failures of ring fixators, both Ilizarov
and hybrid devices, occurred in the
treatment of more severe injuries. Use
of such methods to treat severely dis-
rupted soft tissues and highly commi-
Fig. 2
Clinical photograph of a ring fixator in the completely dynamic mode. The inner nuts are turned
back a few millimeters when the fracture is thought to be almost completely healed. This maneu-
ver dynamizes the fixator and stimulates maturation of the healing callus. Note that tape (arrow)
has been applied to the nuts to prevent drift.
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E X T E R N A L F I X A T I O N : H OW
nuted articular segments was doomed
to fail and, in short, the application of
these frame designs was pushed beyond
their abilities. Thus, it was less the fix-
ator and more the indication or appli-
cation that was at fault. If applied for
the proper indication, hybrid frame
designs can work well15. Furthermore,
application of these fixators is not like
insertion of a plate or nail (passive
management) since it requires active
(but simple) management. The recom-
mended application and management
of a hybrid frame (Fig. 1) will be out-
lined later.
External Fixators and
Magnetic Resonance Imaging
A new issue that has arisen is the safety
of external fixator parts during mag-
netic resonance imaging of either the
limb or other body parts. Magnetic res-
onance imaging-safe means that a fix-
TO M A KE I T WO R K
ator does not generate any deleterious
effects (no known hazards) in any mag-
netic resonance environment. Mag-
netic resonance imaging-conditional
means that the individual parts do not
generate any deleterious effects in spe-
cifically defined (e.g., 1.5-T) magnetic
resonance environments. There are
three issues related to safety during
magnetic resonance imaging:
1. The magnetic field causes a
diret force on magnetic materials. It is
not a problem with nonmagnetic steel,
aluminum, carbon, or plastic.
2. Induced electric currents can
be produced in a magnetic field. Most
modern fixator components are not
individually magnetic, but when the
components are linked together, as in a
standard fixator frame, a closed circuit is
created and an electric current can be in-
duced by the magnetic field. This is true
even when carbon fiber or other non-
metallic material is used because virtu-
ally all elements have some degree of
conductivity and inductivity. A circuit
of magnetic resonance imaging compo-
nents with carbon rods and a loop into
the patient can generate clinically rele-
vant currents16,17.
3. Heating of materials can occur.
The induced current can cause heating
of the device and perhaps local tissue
damage. There is little to no clinical
data regarding this phenomenon, and
the United States Food and Drug Ad-
ministration is yet to rule on what is
considered “safe.” Currently, there is no
industry standard for what is consid-
ered magnetic resonance imaging-safe
or what is clinically safe. Only one com-
pany to date has attempted to “insulate”
the construct against any inductive cur-
rents, but there is still a known temper-
ature gradient that forms.
The resultant interaction of the
frame with the machine itself can dis-
turb the calibration of the magnetic
resonance machine, which can be
damaging and costly to repair. Finally,
even when it is possible to perform
magnetic resonance imaging on a pa-
tient with an external fixator, clamps
located near the field being scanned,
even when several centimeters from
the skin, can result in enough interfer-
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Fig. 3-A Fig. 3-B

Schematic illustrations of humeral (Fig. 3-A) and elbow (Fig. 3-B) frames.

ence to make the scan meaningless. We
recommend judicious use of magnetic
resonance imaging, with the fixator
clamps placed as remote from the area
of interest as possible18. In addition, it
should be remembered that magnetic
resonance imaging safety with regard
to the individual components of the
fixator does not ensure safety of the
magnetic resonance imaging when the
frame is assembled into a closed circuit,
and one should beware of misleading
marketing claims in this regard.
signs. In these designs, a ball is eccentri-
cally turned to lock an interference fit
into place, but if there is even minimal
loosening the entire mechanism may
suddenly release; therefore, we prefer
locking mechanisms other than the
ball-cam design.
The technique for definitive fixa-
tion is based on the concept of the sta-
ble base as taught by James Hutson,
MD (personal communication). With
this method, each fixation segment has
a stable configuration of pins or wires
and an external fixation module (ring,
clamp, or bar). Then individual stable
bases are connected to each other in
the desired orientation. Frequently, a
common bar or clamp can be used for
more than one segment (transport
frames), but ensuring that each inde-
pendent segment has a stable configu-
ration is important. Our preference is

Use of the External Fixator

as Definitive Fixation
The external fixator is an ideal device
with which to obtain healing because it
is one of the only devices that provides a
stable construct in which the mechani-
cal parameters (rigidity and alignment)
can be modulated as needed through-
out treatment. The frame is usually ap-
plied to create as much stability as
possible at the fracture site. Later, with
minimal adjustments, the system can be
made more flexible to allow micromo-
tion or macromotion to help stimulate
healing of the fracture. Furthermore, if
problems develop with parts other than
the pins or wires, those parts are easily
replaced. With modern designs, there
have been very few reported failures or
broken parts, although exceptions do Fig. 3-C
occur with some of the ball-cam de- Clinical photograph of an elbow damage-control frame.
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previously, the first stage of application

of the external fixation should achieve
a rigid construct to allow the earliest
stages of the fracture-healing process to
begin as well as to allow the soft tissues
to recover. Once there is early callus for-
mation, the frame needs to be progres-
sively “destiffened” to transfer more
and more load to the developing callus.
If the construct is made too flexible too
early, the resultant strain may exceed
the local limits of the developing callus
and produce a nonunion. In contrast,
if there is insufficient load transfer,
there will be inadequate callus forma-
tion, bone resorption, and disuse os-
teopenia. Both of these situations are
undesirable. Removing bars, adjusting
the locations of bars, or removing pin
and/or wire components can destiffen
the construct in a systematic way to
achieve fracture-healing.
With use of ring designs, the load
transfer is usually a repetitive stimulus
that occurs with increased physiologic
Fig. 4 loading. As healing progresses, wires
Diagram of pin placement into the pelvis. The bold lines demonstrate the direction of desired and half-pins can be removed or sup-
pin placement (in the case of imperfect pin placement) for two fracture types. If the pelvis is port struts can be loosened. Finally,
being “closed” (right part of picture), then pin placement should not traverse the ilium to the intervening struts can be removed alto-
outside (non-bold lines) but instead should traverse to the inside. The forces on the pin-bone gether, and the patient can have a trial
interface during reduction are better resisted in this fashion. Likewise, on the left side, the of weight-bearing. This is done so that,
pelvis is being “opened” and the opposite is true. This situation is relatively rare. if pain occurs with weight-bearing, the
struts can be reapplied with the pre-
sumption that healing is incomplete
to place at least three or four fixation nized or necrotic tissue that could and a repeat trip to the operating room
wires or half-pins (for a metaphyseal increase the risk of infection. We to reapply removed “stable bases” is not
segment) or three half-pins (for a dia- also treat the patient with a broad- required.
physeal segment) so that one or two spectrum antibiotic for one or two If a modular or monolateral de-
can be removed if necessary without weeks before placing the internal fixa- sign is used in the tibia, the key element
destabilizing the construct. In the tion. Although there is little evidence is the anteromedial stabilizer since the
event that the fracture does not heal or on which to base this recommenda- center of gravity is medial during single-
another problem requires removal, the tion, we believe that the morbidity and limb stance. Having main fixator struts
frame should be removed and the frac- costs of a subsequent infection justify or bars near the center of gravity mini-
ture should be controlled with external the use of such a protocol19. mizes the cantilever load on the fixator
bracing for one to two weeks prior to There have been several studies in pins. With a true monolateral system,
internal fixation. The infection rate as- which the different healing patterns of the frame is placed in the anteromedial
sociated with intramedullary nailing fractures have been measured while the quadrant of the leg, and, as healing
after external fixation is relatively low extremity was in an external fixator3-6. progresses, the fixator is either manu-
(8%) in the absence of a true pin-track In these studies, the stiffness and strain ally compressed or progressively dyna-
infection, but most traumatologists of the fracture callus were measured mized. In modular hybrid constructs,
recommend an interval of frame re- during the healing process and the au- there is an anteromedial strut and a sec-
moval, pin-track curettage, and per- thors outlined how healing occurs. The ondary bar that connects to the lateral
haps antibiotic coverage prior to common finding of these studies is that, side of the leg and creates a triangular
placement of the intramedullary nail. if the fracture is to heal, a proper load or delta-shaped construct. In these con-
We recommend drilling and curettage transfer from the external fixator to the figurations, the delta bars are the first
of the pin tracks to remove any colo- developing callus is necessary. As noted to be removed. This is followed by mov-
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Fig. 5-A Fig. 5-B

Fig. 5-A Schematic of a femoral frame. Fig. 5-B Montage of external fixator placement in the intensive care unit for damage-control. Local prepara-
tion and sterile technique are used to place pins percutaneously. Two stable bases are created (bottom left) and connected to stabilize the femur
(bottom right).

ing the anteromedial bar farther from
the skin or by reducing the number
of pins and/or wires in each segment.
While there are several methods avail-
able to decrease stiffness and allow load
transfer to the healing callus, these ac-
tions are done only when there is am-
ple radiographic and clinical evidence
of healing (callus progression and pain-
free function). Before complete dynam-
ization occurs, a trial of disconnection
with weight-bearing (usually in the
physician’s office or for one week) is
carried out to ensure that clinical heal-
ing is occurring (Fig. 2).
External Fixator Configurations
for Damage-Control Frames
These are the simplest of frames, and
many configurations are possible. The
ones described here allow percutane-
ous placement (away from vital struc-
tures) while providing adequate initial
stability and wound access and mini-
mizing the risks associated with de-
layed internal fixation.
Humerus: Five-millimeter pins
should be placed in the anterolateral
quadrant of the proximal part of the
humerus and in the posterolateral
quadrant of the distal part of the hu-
merus. Fine wires and 4-mm pins can
be used in very distal fragments (Figs.
3-A, 3-B, and 3-C).
Forearm: In most of the forearm,
the subcutaneous border of the ulna
can be used as a suitable landmark, but
only 3-mm (distal) or 4-mm (proximal)
pins should be employed. The radius is
not as suitable for percutaneous fixa-
tion, and an open approach is recom-
mended if such fixation is used.
Pelvis: The anterior superior il-
iac spine is an excellent landmark, and
5-mm pins should be directed medially
and posteriorly. If the fixator is to be
used to reduce an “open-book” type of
pelvic fracture (e.g., internal rotation
of the hemipelvic segments), the pin
should not exit the iliac wing laterally
because, with manipulation of the dis-
placed pelvic fracture, the pins can just
rotate in the iliac crest, leaving the frac-
ture unreduced. Also, such pins will
become loose and contribute to skin
problems. In these cases, it is preferable
to err with the pin exiting the inner ta-
ble so that, during the reduction ma-
neuver, pin rotation is resisted by the
inner table of the ilium (Fig. 4). Con-
versely, if the fixator will be used to
“open” the pelvis, as in the treatment
of a lateral compression injury, pin
placement should err to the outer cor-
tex for similar mechanical and soft-
tissue reasons. If needed, a superior
acetabular pin can be placed 5 to 10
cm proximal to the tip of the greater
trochanter in line with the femur to
provide fixation. Care should be taken
that this pin does not penetrate into the
soft tissues of the pelvis. Alternatively,
through an open approach, the anterior
inferior iliac spine can be used for pin
placement with the pin directed posteri-
orly. We recommend against placing
pins in the greater trochanter because
of the high risk of infection.
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Fig. 6
Schematic of a tibial frame. Note that pins
are placed anteromedially when possible.
Femur: Along the entire length of
the femur, the anterolateral quadrant is
best suited for placement of 5-mm pins.
The anterolateral aspect of the thigh
contains no vital structures, and the pin
tracks do not interfere with subsequent
surgical approaches (Figs. 5-A and 5-B).
Tibia: The anteromedial quadrant
is best suited for 5-mm pins, as there is
little soft tissue and easy access. We place
the pins perpendicular to the anterome-
dial face of the tibial cortex (Fig. 6).
Knee: The knee can be stabilized
with placement of pins into the antero-
medial aspect of the tibia and the ante-
rolateral aspect of the femur to create a
stable base in each segment. A single
large bar should be connected to each
pin pair with adequate length to connect
to another bar. An intercalary bar com-
pletes the zigzag or z construct (Fig. 7).
Ankle: The ankle can be stabilized
with use of a single 4 or 5-mm trans-
fixion pin across the calcaneus, with or
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E X T E R N A L F I X A T I O N : H OW TO M A KE I T WO R K
without the addition of 4-mm midfoot and 9-B). The hybrid frame is best
or metatarsal pins. Because of problems used for extra-articular or very simple
with loosening of transfixion pins in fractures (C1 according to the AO/OTA
the calcaneus, we now prefer to use classification system). Originally, one
two posterior calcaneal pins attached to would use two or three wires and/or
a u-shaped bar or ring. These pins seem one or two half-pins in the articular
to create fewer problems. We would cau- segment with a longitudinally parallel
tion against placing two transverse pins support member in the anteromedial
into the calcaneus because of the risk of quadrant of the leg and a delta sup-
damage to vital structures on the me- port bar. As soft tissues stabilize and
dial side, such as the flexor tendons and weight-bearing is initiated, the surgeon
the neurovascular bundle20,21 (Fig. 8). monitors the radiographs for evidence
of healing. If callus is present (at ap-
Stable Base proximately two to four weeks), load
When building an external fixation transfer is initiated by one of several
frame, one should first create a stable methods. Having the patient bear
base in each bone segment. To achieve weight statically while the delta bar
this, a single bar is placed between the is loosened and then retightened re-
two pins in each fragment. Then an- sets the load on the bar and effectively
other bar (an intercalary bar) is con-
nected to the bars in each base. For
example, when two pins are placed into
the femoral fragments, there should be
a bar that connects the two pins in each
fragment, and then an additional bar is
used to stabilize the fracture. If the inter-
calary bar is connected to only one of
the two pins in each base, the resultant
stability of the construct may be inade-
quate because the holding power and
the stability of a bar-to-bar connection
is greater than that of a bar-to-pin
connection. Another strong recom-
mendation is to place the compart-
ment, through which a pin is passing,
on stretch during insertion. For exam-
ple, if a wire is passing across the distal
part of the femur from posterior-lateral
to anterior-medial, the knee is straight-
ened (to place the posterior muscle-
tendon units on stretch) during initial
insertion; then, as the pin exits antero-
medially, the knee is flexed (to place the
medial quadriceps muscle-tendon units
on stretch). This maneuver not only
helps maintain motion around the ad-
jacent joint but also minimizes irrita-
tion by the pin during such motion.
This can help minimize irritation of
the tissues and facilitate pin care.
Application of a Hybrid
Frame to the Tibia Fig. 7
The application of a hybrid frame to Schematic of a knee frame. The femoral
either the proximal or the distal part of pins are anterolateral, and the tibial pins
the tibia is relatively simple (Figs. 9-A are anteromedial.
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mately six weeks), more load is trans-

Fig. 8
A loose calcaneal transfixion pin associated with infection (left) and a pin inserted posteri-
orly and attached to a u-shaped bar or ring (right).
transfers some load to the bone. Re-
moval of a wire or pin will also des-
tiffen the construct, but we recommend
against this method in case any prob-
lems develop with the remaining pins.
If a dynamic component has been used,
it can be dynamized as described be-
low. In the absence of a dynamic
component, another, more practical
method is to move the bar farther from
the skin (bone), which would effectively
decrease the stiffness of the frame and
result in greater load transfer at the site
of callus.
Progressive weight-bearing in-
creases load transfer. When a dynamic
device is used, as is our preference, load
transfer can be started by dialing 1 mm
of axial motion into the system. As
healing progresses (i.e., at approxi-
ferred by increasing weight-bearing
further and by removing the delta bar.
With dynamic components, more mo-
tion can be dialed in. This process is
continued so that, by twelve weeks,
some half-pins can be removed and/or
more motion can be dialed in. At six-
teen weeks, if the radiographs and clini-
cal status warrant it, the components
are disengaged while the metaphyseal
and diaphyseal stable bases are main-
tained. This allows full load transfer
while keeping the frame components in
the leg but not connected in case heal-
ing is incomplete and more time in the
fixator is required. The remainder of
the device is removed one week later if
the patient has no symptoms and the
fracture remains aligned. With use of
this algorithm, if there is satisfactory
initial reduction, progressive physio-
logic loading, and progressive dynam-
ization (load transfer), fracture-healing
can frequently be expected. In our ex-
perience with a series of proximal and
distal tibial fractures, this method was

Fig. 9-A Fig. 9-B

Fig. 9-A Example of initial hybrid application with use of an anteromedial strut and a delta bar. This con-
figuration established initial rigidity for both soft-tissue healing and initiation of the fracture-healing cas-
cade. Fig. 9-B After two to four weeks, when there are some radiographic signs of callus formation, the
fracture is progressively loaded in a controlled fashion. The fixator is destiffened with use of one of sev-
eral methods. These include removal of the delta bar; changes in the bar-bone distance (farther equals
less stiff); removal of pins or wires; or, in the present example, use of a dynamic axial bar that allows
controlled spring loaded axial micromotion.
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well tolerated and resulted in a healing
rate of >95%15. It should be noted, how-
ever, that this method is indicated for
only specific fracture types. In order
to avoid the problems reported in the
past with use of a hybrid device, it is
important to understand the appropri-
ate indications for its use. As the saying
goes, one needs “the right tool for the
right job.”
Pin Care
Localized pin-track infection has been
the nemesis of external fixation and one
of the primary reasons many surgeons
avoid its use. The anatomic sites that are
most prone to pin-related problems are
those with a large soft-tissue sleeve and
those subject to motion of the soft tis-
sues. Excessive motion of the muscle
and skin around the bone results in lo-
cal inflammation that leads to a pin-
track infection and in turn can progress
to infect the bone. What appears to be
clear to most experienced surgeons is
that the most important parameter is
the control of soft-tissue motion. Stabi-
lizing the soft tissues around the pin
to prevent motion is probably more
important than the method or agent
of cleaning. There are numerous meth-
ods with which to stabilize the skin.
One of the best is application of a gentle
compressive dressing between the bar
and skin. With this method, it is im-
portant to avoid excessive pressure
and skin necrosis.
Pin-care protocols range from
doing nothing to washing the site of en-
try three times a day with cotton swabs
and peroxide. Temple and Santy per-
formed a comprehensive review of
studies on pin care in the literature22.
They found one randomized, con-
trolled study in which saline solution,
alcohol, and no cleaning were com-
pared, and no cleaning resulted in fewer
infections. Another study demonstrated
no difference between daily and weekly
pin care23. There is now sufficient evi-
dence that elaborate pin care is not nec-
essary and that simple and occasional
attention to the pins may be sufficient.
Most practitioners recommend daily
pin care performed for personal hy-
giene reasons. There is no evidence that
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E X T E R N A L F I X A T I O N : H OW
any one modality or chemical works
better than another, but we recom-
mend a non-tissue-toxic cleaner such
as soap. It would seem that pin site ir-
ritation leading to inflammation is a
probable mechanism that results in in-
fection and, finally, loosening of the
pin. Therefore, minimizing mechanical
skin motion may be more important
than the frequency of cleaning or type
of cleaning agents24 (Fig. 10).
We developed a pin-care protocol
that has served us well but is not based
on scientific data. As previously de-
scribed, when a pin is being inserted,
the soft-tissue compartment should be
placed on stretch and the skin should be
released if needed so that there is no skin
tension. The pin sites are covered and, to
ensure that there is no pistoning of the
soft tissue, we use bolsters, spacers, or
sponges to stabilize it. The pin sites are
left covered and are not inspected for as
long as the patient is in the intensive
care unit. If the pins are cleaned during
the inpatient stay, we use saline solution
or alcohol and do not probe the tracks
with cotton swabs. Nursing staff and
aides do not provide pin care. The pin
sites are gently wiped with an alcohol
pledget and then covered. The sur-
rounding skin is stabilized by placing a
bolster between the bar and skin that
applies gentle pressure to the skin and
prevents motion with routine activity.
Fig. 10
Three pins, with no associated infection, with pin clips that were used to hold the
dressings in place.
TO M A KE I T WO R K
The patient is instructed to
shower daily after he or she is dis-
charged and to clean the fixator with
soap and water in the shower as part of
a daily routine. The skin and pins are
dried with a clean towel, and the pin
sites are wiped with an alcohol pledget.
The skin is then stabilized as described
above. Bath water, fresh-water lakes,
and sea water are avoided.
Problems with pin-track infec-
tion should be managed as quickly as
they are identified. We use the classifi-
cation of Checketts et al.25,26. While the
literature often describes relatively high
rates of “pin-track infection,” close in-
spection will demonstrate that the ma-
jority of pin-related problems fall into
the Checketts grade-I and II categories,
which are very mild. A problematic pin
is one associated with ongoing exu-
dates or purulent discharge with sur-
rounding inflammation and subsequent
loosening. When a pin site looks irri-
tated, we first assess the nature of the
pin care being provided. We then check
the stability of the pin in bone and of
the entire construct. If the pin or con-
struct is loose, any and all pin care will
usually be futile. We stratify our pin
problems in two ways, according to sta-
bility and inflammation. Any pin that is
unstable and associated with inflamma-
tion is removed. Pins associated with
inflammation and transudate that are
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Fig. 11
Suppuration around a pin that requires aggressive treatment. Modalities include
more frequent cleaning, the application of Bactroban (mupirocin) cream, and a full
dose of oral antibiotics. The pin should be tested for tightness. If it is loose, it
should be removed or replaced.
stable (Checketts grades I and II) are
retained25. We begin by ensuring proper
skin stability, and we frequently apply
Bactroban (mupirocin) ointment. Pins
that are associated with inflammation
and purulence are at greater risk. In ad-
dition to all of the interventions pro-
vided for grade-I and II problems, we
add oral antibiotics in adequate doses
(Keflex [cephalexin], 500 mg four times
a day, or Levaquin [levofloxacin], 500
mg daily) because suboptimal antibiot-
ics are not only ineffective but also can
lead to the development of resistant or-
ganisms (Fig. 11). We also increase the
frequency of cleaning if there is accu-
mulation of dried exudates. If after such
interventions there is no improvement,
1. Pauwels F. [A new theory on the influence of me-
chanical stimuli on the differentiation of supporting
tissue. The tenth contribution to the functional anat-
omy and causal morphology of the supporting struc-
ture]. Z Anat Entwicklungsgesch. 1960;121:478-
515. German.
2. Perren SM. Evolution of the internal fixation of
long bone fractures. The scientific basis of biologi-
cal internal fixation: choosing a new balance be-
tween stability and biology. J Bone Joint Surg Br.
2002;84:1093-110.
1631
E X T E R N A L F I X A T I O N : H OW
we then check the stability of the pin
again, and if it is loose we remove it.
Also, as noted previously in our de-
scription of the method of application,
the use of three or four fixation points
in each segment provides the latitude of
being able to remove one or two pins
during treatment without compromis-
ing the outcome or necessitating a re-
turn to the operating room. With this
methodology, we have substantially lim-
ited the need to revise pins, and patients
have tolerated fixators very well.
Overview
The external fixator is a useful tool
for a number of applications, from
damage-control to definitive treat-
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ment. Advanced applications can be
used to treat deformity, infection, and
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External fixation is not the best treat-
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situations.
Bruce H. Ziran, MD
Northeastern Ohio Universities College of
Medicine, St. Elizabeth Health Center, 1044
Belmont Avenue, Youngstown, OH 44501.
E-mail address: Bruce_Ziran@hmis.org
Wade R. Smith, MD
Department of Orthopaedics, Denver Health
Medical Center, 777 Bannock Street, Denver,
CO 80204
Jeff O. Anglen, MD
Department of Orthopaedics, Indiana Univer-
sity, 541 Clinical Drive, Suite 600, Indianapo-
lis, IN 46202
Paul Tornetta III, MD
Department of Orthopaedic Surgery, Boston
Medical Center, 850 Harrison Avenue, D2N,
Boston, MA 02118
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