1st Zliten Orthopedic Symposium (ZOS) 10th March,2016 External Fixation Dr.Mohamed Ali Gwila MRCS(Edinburgh), MSOrth(Malaysia) Department of Orthopaedic & Trauma Surgery Zliten Teaching Hospital (ZTH)

Definition “A device place outside the skin which stabilizes the bone through wires or pins connected to one or more longitudinal bars” AO principles of Fracture management

Types Available in Our Hospital Stryker-Hoffmann II (Large ,Medium & small ) Galaxy –Orthofix.

Types

Why / When do we use External Fixators? Open fractures stabilization When internal fixation contraindicated For dressing purposes Definitive surgery later

Why / When do we use External Fixators? Initial stabilization of polytrauma patients Prevents “secondary insult” to the body “Damage Control Orthopedics” By stabilizing fractures early, surgeons are able to limit blood loss, decrease patient pain, improve short- and long-term patient outcomes and take additional time to plan for definitive treatment.

Why / When do we use External Fixators? Closed fracture with severe soft tissue injury i.e burn / severe abrasion Internal fixation contraindicated In Children’s fractures Primary treatment for fracture of the femur

Why / When do we use External Fixators? Bridging the articular fractures Reduction by ligamentotaxis

Why / When do we use External Fixators? Pelvic ring fractures For stabilization of the ring

Why / When do we use External Fixators? Correction of deformities Correction of limb length discrepancy Arthrodesis

ADVANTAGES / DISADVANTAGES

Advantages Stabilizes bone - distant from the operative or injury focus Minimal additional vascular trauma to bone Lower risk of infection Access for wound care Easy to apply Easy to remove

Disadvantages Pin tract infection / loosening Delayed fracture union Patient discomfort Restricted joint motion – across joint Not as rigid as internal fixation

COMPONENTS Pins Stainless steel Tubes or carbon fibre rods Schanz screw / steinman pin Stainless steel Tubes or carbon fibre rods Clamps / connectors Pins to tubes Tubes to tubes Illizarov : Olive / K-wire , rings

6 Basic Configurations Unilateral frame, One plane Unilateral frame, Two planes Bilateral frame, one plane Bilateral frame, two planes Multi-planar Hybrid

Unilateral Frame, One Plane

Unilateral frame, two planes (Delta Frame)

Bilateral Frame, One Plane

Bilateral frame, Two plane Now seldom used

Multi-planar

Hybrid

Principles

4 Basic Principles of Application Vital limb anatomy Injury access Mechanical Stability Patient comfort

Vital limb anatomy DO: Remember Safe pin insertion sites insert Pin / screw into opposite cortex, Subcutaneous insertion, avoiding muscular impalement which decreases pain and increases function DON’T: Protrude too far from opposite cortex Injure nerves or vessels Place into the joint Place into fracture line

Injury Access Fixator frame not to interfere with wound care Bars / rods not too low to the skin Schanz screws / pins not too near / inside the wound

Increasing Mechanical Stability Increasing pin diameter: - most important factor in fixator stability; - adult tibia: usually requires fixation w/ 4.5 to 6.0 mm pins - pins must be < 1/3 bone diameter to prevent pin hole fractures;

Increasing Mechanical Stability widely separated pins within single fragment Increasing number of shanz screw Preloading shanz screw Reducing distance btw bar and bone Add 2nd bar to frame Use of multi-planar fixator

Patient comfort Simple unilateral fixator Short shanz screw

Complications Pin tract infection Presented with pain, redness, discharge, loosening X-ray = osteolysis around pin Chronic osteomyelitis = ring sequestra

Thank you for attention