Skeletal Trauma 6th Edition-8-Min
Skeletal Trauma 6th Edition-8-Min
Skeletal Trauma 6th Edition-8-Min
Complications o External
Skeletal Fixation
Stuart A. Green | Wade Gordon
Additional videos related to the subject o this chapter are in large dogs5—and the external xator of Swiss physician
available rom the Medizinische Hochschule Hannover Raoul Hoffmann (1938)6 (Fig. 8.2).
collection. Several of these devices saw use during World War II.
The ollowing videos are included with this chapter and Toward the end of that cataclysm, however, the high incidence
may be viewed online at Expert Consult: of complications associated with external xation became
HISTORICAL BACKGROUND
EARLY FIXATORS
The external xator was invented 12 years before the plaster
cast. In 1846 Jean Francois Malgaigne devised an ingenious
mechanism consisting of a clamp that approximated four
transcutaneous metal prongs to reduce and maintain patellar
fractures1 (Fig. 8.1). In the 170 years since Malgaigne’s
invention, many other external xation systems have been
introduced. Among the best known are the Parkhill bone
clamp (1897),2 Lambotte’s monolateral external xator
(1902),3 Roger Anderson’s 1934 xation system,4 the 1937
Stader apparatus—originally developed for managing fractures
Fig. 8.1 Malgaigne’s 1846 external xator for patellar fractures.
A B C D E
Fig. 8.2 Historic external xators. (A) Parkhill bone clamp. (B) Lambotte xator. (C) Anderson apparatus. (D) Stader apparatus. (E) Hoffmann
xator.
207
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208 Section one — General PrinciPleS
apparent. The major disadvantages noted by a military of complications with their techniques, some of which are
commission who studied the matter included nerve and unique to limb lengthening.14
vessel injuries by pins, the presence of soft tissue infections In Russia, external xation as a modality for fracture
at the pin sites, the possibility of ring sequestra and osteo- treatment remained viable in the period subsequent to
myelitis, and the danger of delayed union or nonunion. World War II. Surgeons in that country focused attention
Other surgeons were distressed by the mechanical difculty on ring-type xators that were connected to the bone by thin
associated with external xators, as well as by the prospect transxion wires tensioned by special wire-gripping clamps.
of converting a closed fracture to an open fracture.2 As a Although these xators were quite cumbersome, some
consequence, by 1950 most American orthopaedic surgeons contained ingeniously geared articulations that permitted
were not using mechanical xators although the pins-in-plaster precise displacement of the rings in any of three planes
technique was used for special problems, such as unstable independently.
wrist fractures7 and displaced fractures of the tibia and
bula.8
CIRCULAR FIXATORS
In Europe, conversely, clinical research on external skeletal
xation continued throughout the years during and after In 1951 Dr. Gavriil A. Ilizarov of Kurgan in the former Soviet
World War II. Raoul Hoffmann improved his device, providing Union developed the rst model of his transxion-wire
a stronger universal joint and an enlarged pin-gripper that circular xator, which is still used today15 (see Fig. 8.3C).
held the pins more securely. Charnley, of England, presented Other Soviet surgeons subsequently designed similar devices,
his concept of compression arthrodesis of the major joints,9 some with geared couplers that allowed gradual repositioning
using a rather simple skeletal xator that provided continuous of bone fragments. Within a few years, Ilizarov discovered
compression of cancellous surfaces of the joint to be fused. that bone would form in a widening distraction gap under
In time, the Arbeitsgemeinschaft für Osteosynthesefragen appropriate conditions of stability, delay, and distraction.16
(AO) group of Switzerland modied Charnley’s device to His observations and subsequent clinical research revolu-
more pins in his frame conguration.10 tionized deformity correction and limb salvage surgery and
Also in France during the 1960s, Jacques Vidal and cowork- contributed to a revived worldwide interest in circular external
ers used Hoffmann’s equipment but designed a quadrilateral xation.17
frame to provide rigid stabilization of complex fracture Ilizarov’s apparatus consists of separate components that
problems and septic pseudarthroses under treatment11 can be assembled into an unlimited number of different
(Fig. 8.3A). congurations that allow a surgeon to perform all of the
following:
FIXATORS FOR LIMB LENGTHENING
• The percutaneous treatment of all closed metaphyseal and
External xators specically designed for limb lengthening diaphyseal fractures, as well as many epiphyseal fractures
began to appear after W. V. Anderson developed an apparatus • The repair of extensive defects of bone, nerve, vessel, and
that employed full transcutaneous pins connected to threaded soft tissues without the need for grafting—and in one
bars.12 The device permitted gradual distraction of an oste- operative stage
otomized bone. Heinz Wagner,13 working in Germany, • Bone thickening for cosmetic and functional reasons
modied Anderson’s concept even further, substituting • The percutaneous one-stage treatment of congenital or
half-pins for Anderson’s full pins, while employing a universal traumatic pseudarthroses
distraction bar that patients could lengthen themselves (see • Limb lengthening or growth retardation by distraction
Fig. 8.3B). These pioneers accurately recorded the incidence epiphysiolysis or other methods
A B C
Fig. 8.3 Modern external xators. (A) Vidal quadrilateral frame. (B) Wagner limb lengthener. (C) Ilizarov apparatus.
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cHaPter 8 — PrinciPleS and comPlicationS of external Skeletal fixation 209
• The correction of long bone and joint deformities, includ- These xators, which are often referred to as hybrid designs,
ing resistant and relapsed clubfeet usually combine an Ilizarov-type ring with an AO-type tubular
• The percutaneous elimination of joint contractures bar. The tensioned wires are secured to the ring (which
• The treatment of various arthroses by osteotomy and surrounds the cancellous portion of the bone) while the
repositioning of the articular surfaces bar connects to half-pins in the cortical bone.
• Percutaneous joint arthrodesis Ring xators have a distinct advantage over unilateral or
• Elongating arthrodesis—a method of fusing major joints bilateral devices because the apparatus—especially Ilizarov’s
without concomitant limb shortening device—permits a surgeon to gradually reposition fracture
• The lling in of solitary bone cysts and other such fragments (or osseous fragments after osteotomy) with respect
lesions to each other in three-dimensional space. To match this
• The treatment of septic nonunion by the favorable effect capability, several new unilateral xators incorporate geared
on infected bone of stimulating bone healing articulations that permit the controlled movement of one
• The lling of osteomyelitic cavities by the gradual collapsing pin-gripper with respect to the others.
of one cavity wall
• The lengthening of amputation stumps
FIXATORS FOR SEVERE TRAUMA
• Management of hypoplasia of the mandible and similar
conditions One modern concept of care for severe polytrauma starts
• The ability to overcome certain occlusive vascular diseases with the application of a simple external xator for prelimi-
without bypass grafting nary stabilization of each seriously injured limb, followed by
• The correction of achondroplastic and other forms of more denitive reconstruction later on.21 The goal of most
dwarsm surgeons who apply a xator for the temporary stabilization
of a limb is to convert from external xation to internal
An American orthopaedist David Fischer visited Moscow xation, usually an intramedullary nail. The concept is
in 1975 where he obtained several different Soviet circular discussed at length later in the section, “Using the Atlas for
external xators. After applying these frames to his own Damage Control Orthopaedics.”
patients, he became concerned with the problems of frame Although a number of protocols have been recommended
instability associated with transxion wires, as well as the to reduce the likelihood of such an infection, one promising
perceived weight of the circular frames he tried. Thereafter, concept has been the development of a “pinless” external
Fischer developed a circular xator, which attached to bone skeletal xator by the AO group. With this device, a spring-
via full pins and half-pins.18 The entire system was originally loaded pair of pins that resemble ice tongs, which grip the
fabricated from titanium—a lightweight yet strong metal. In cortex but do not penetrate into the endosteal surface,
general, he noted fewer pin-site infections when his device secures bone fragments. In this manner, the medullary
was mounted with titanium pins instead of steel implants. canal is (in theory, at least) free of microbial contamination.
Moreover, when titanium pin-site sepsis did occur, the Time will tell if such an invention reduces the incidence
reaction was more benign appearing, with far less cellulitis of implant sepsis when an intramedullary nail replaces an
and soft tissue reaction than was commonly observed with external xator.
steel pins. A complete understanding of the ideal milieu for rapid
North American orthopaedic surgeons, exposed to Ilizarov’s fracture healing has yet to be ascertained. Around the world,
methods by Italian practitioners in the mid-1980s, modi- pioneering clinicians and researchers are using xators to
ed Ilizarov’s technique. Among the most useful of these study the inuence of stability, distraction, and compression
improvements has been the fabrication of rings and plates on fracture healing and regenerate new bone formation.
of the Ilizarov apparatus from radiolucent carbon ber. This The results of these studies will certainly advance the clinical
material, though more expensive than steel, is substantially applications of both internal xation and external xation
lighter and thus popular with the patients. and improve fracture care in general.
At Rancho Los Amigos Medical Center, the author and When trauma surgeons discovered in the mid-1980s
his coworkers began using titanium half-pins (in place of that open fractures could safely be treated with intra-
steel wires) to secure Ilizarov’s circular xator to long bones medullary nails, it appeared that external xation’s role
requiring either limb lengthening or deformity correction.19 in orthopaedic surgery would be greatly diminished.
In this manner, the adaptability of the circular device was Ilizarov’s discovery of distraction osteogenesis, however,
retained, but the problem of muscle impalement and trans- has rendered the prediction of external xation’s demise
xion was reduced, especially in bones such as the ulna premature indeed. Fixators have become an important part
or tibia that have large subcutaneous surfaces. In certain of deformity correction, especially where limb elongation
anatomic locations, however, wire mounts still appeared is a concomitant requirement. For this reason, worldwide
superior to pin mountings—especially in the juxtaarticular use of external skeletal xation is on the rise again, as it
regions where cancellous bone predominates. For more was before World War II and again in the 1970s and early
substantial fragments that include both the articular and 1980s.
metaphyseal regions, combinations of pins and wires have
proven successful for mounting circular external skeletal
COMPUTERIZED CORRECTION
xation.20
Several new xator congurations have been devised speci- In the 1990s Dr. Charles Taylor—codeveloper of the Russell-
cally for applications that require anchorage in cancellous Taylor intramedullary nail—realized that the reduction of a
bone at one end of the frame and cortical bone on the other. displaced bone fragment (or correction of a deformity) could
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210 Section one — General PrinciPleS
be accomplished by mathematically dening the path a bone its developers and manufacturers as the next step in deformity
fragment travels as it moves from its displaced position to correction technology. Time will tell if a true advance has
its corrected position.22 Using an ingenious design, Taylor occurred.
connected rings of an Ilizarov-type circular xator to one The disruptive technology in the eld of reconstructive
another with six struts, each of which could be independently limb surgery, however, is the introduction of intramedullary
lengthened or shortened (Fig. 8.4). In this way, the relation- lengthening nails that reliably elongate in response to an
ship between the rings can be altered in a precise manner, externally applied force, either electrical, magnetic, or
modifying the relationship of the rings—and their attached mechanical. The expanding indications and application of
bone fragments—to one another.22 this technology are covered in depth in a separate chapter
After measuring the precise displacement of the bone in this book.
fragments and the relationship between the fragments and
their respective rings, the data are fed into a computer that
COMBINED INTERNAL AND EXTERNAL FIXATION
has been programmed to determine the pathway to reduction
in all planes—angulation, rotation, shortening, and transla- Certain additional developments have occurred since the
tion.23 Moreover, the computer program outputs a schedule previous edition of this book. External xation is now fre-
of strut length changes needed to effect the reduction at quently combined with internal xation to reduce the total
whatever predetermined speed is needed for both safety time and external xation frame.25–27 This strategy not only
and efcacy. The system, called the Taylor Spatial Frame, is reduces patient discomfort and problems with activities of
quite popular with surgeons who have become familiar with daily living, but also reduces the incidence of pin tract infec-
its use (see Video 8.2).24 tions, which rises slowly but steadily during the time a xator
Since the previous edition of this book, the patent on the is in place. This evolution started with lengthening over an
Taylor Spatial Frame’s computer interface expired, a fact intramedullary nail, a strategy devised in the Baltimore
that has led to the introduction of several hexapod systems protocol by Paley and coworkers,28 whereby an intramedullary
with surgeon-friendly computer interfaces, each lauded by nail is inserted into a bone after osteotomy for limb elonga-
tion. During the same operative session, an external xator
is applied to the limb with care to avoid contact or even
close proximity of the transosseous implants with the intra-
medullary implant. This requires careful uoroscopy-
controlled pin or wire insertion.
Typically, pins or wires are inserted from the posterior to
the implant in the femur and tibia, although anterior place-
ment is also acceptable. This strategy is particularly appealing
to patients who can have the xator removed and transverse
locking screws inserted into the limb as soon as the distraction
phase of the treatment protocol has been completed. There-
after, ordinary weight bearing, usually with ambulatory aid
support to protect the implant, continues until the regenerate
bone forms around the implant.
Two comparable strategies have evolved in recent years,
both coming from the group at the Hospital for Special
Surgery in New York.29,30 The rst is lengthening and then
nailing, a strategy that starts out with a typical Ilizarov-type
lengthening that would consist of either a classic ring xator
or a modied ring xator, such as the Taylor Spatial Frame
(particularly if there is concomitant deformity correction),
or even a multilateral xator. Once the deformity is fully
corrected and the bone is straight, with early regenerate
formation in the distraction gap, an intramedullary nail is
inserted and secured with transverse locking screws, and the
xator is removed. Obviously, the transcutaneous transosseous
implants must be inserted in a place far enough away from
the anticipated medullary canal passage of the nail to prevent
contamination by microbes in the pin or wire tract.29,30
Another strategy from the same facility involves the use
of external skeletal xation to achieve length, followed by
the use of a plate and screws to shorten the xator time once
the nal position of the bone has been achieved.29 The advent
Fig. 8.4 The Taylor Spatial Frame. Six adjustable struts control the
relationship between the two rings, one of which must be mounted of locking plates makes such a strategy possible, because the
orthogonal to either the proximal or distal fragment. All deformity and plate often has to span a zone where the regenerate new
mounting parameters are fed into a computer, which calculates the bone is very weak, sometimes only a wispy shadow, thus
strut length changes needed to restore the displaced fragment to requiring a particularly strong and stable plate and screw
anatomic alignment. xation (see Video 8.1).
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212 Section one — General PrinciPleS
FRAME CONFIGURATION A B
PREFABRICATED FIXATORS
External xation systems in which a manufacturer prefabri- E F
cates the components can be divided into two broad categories: Fig. 8.5 Basic xator congurations. (A) Unilateral. (B) Bilateral. (C)
those with xed congurations and those with variable Multiplanar (quadrilateral). (D) Multiplanar (delta conguration). (E) Ring
congurations. xator. (F) Hybrid xator.
Fixed conguration: These external xation frames are
characterized by a relatively xed, but usually adjustable,
spatial conguration that dictates the position, direction, or
number of transcutaneous pins. unsolidied substance that hardens within a few minutes
Variable conguration: The variable conguration xator after being applied. The classic pins-in-plaster technique,
systems are similar to one another in that they consist of methylmethacrylate external pin xation, and epoxy-lled
many separate components that can be assembled into any tube systems belong in this group. These systems permit
spatial conguration as dictated by the nature of the unlimited pin positions, but they lack adjustability and
musculoskeletal problem. Precise pin position is generally preclude compression or distraction.
required only with the individual pins within a cluster (those
held by the same pin gripping clamp).
PROBLEMS, OBSTACLES, AND
IMPROVISED FIXATORS COMPLICATIONS
This category comprises systems of external fracture man- The application of an external skeletal xator, especially
agement where transcutaneous pins are connected to an one that involves the slow repositioning of bone fragments,
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cHaPter 8 — PrinciPleS and comPlicationS of external Skeletal fixation 213
C
Fig. 8.6 (A) A pin or wire directed at a vessel will often push the structure to the side. (B) A vessel resting on an implant may erode and bleed
2 or more weeks after implant insertion. (C) Alternatively, bleeding may occur at the time of implant removal.
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214 Section one — General PrinciPleS
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cHaPter 8 — PrinciPleS and comPlicationS of external Skeletal fixation 215
Fourth, pin positions should have a margin of safety on danger to neurovascular structures. Also, “backing out” a
the opposite side of the bone. A pin is considered “safe” if pin reduces its xation in bone. When the depth of the rst
it passes through the bone and emerges from the opposite pin is satisfactory, additional pins of the same length can be
side of the limb without encountering a major neurovascular inserted to the same depth. This strategy for pin insertion
structure. Such pins are illustrated as full (through-and- can also be employed to reduce radiograph exposure to the
through) pins, although wires or half-pins could, of course, OR personnel when image intensication uoroscopy is used.
be safely inserted from either direction. Only a brief exposure is necessary to determine the position
A pin is labeled “caution” if a major nerve or vascular and depth of the rst pin. Thereafter, pins can be inserted
structure is located on the opposite side of the bone at a to the same depth without checking the progress of each
distance equal to or greater than the diameter of the bone pin individually.
itself. In this respect, the designation refers only to half-pin The cross-section atlas in this book was specically created
placement. A full pin may be labeled caution if the direction to aid the surgeon in the OR. Proper orientation of the
or angle of pin insertion is critical to avoid neurovascular cross-sectional diagrams to a patient on the operating table
injury. depends on the location of easily palpable landmarks. Each
A pin is labeled “danger” if a major neurovascular struc- limb section in the atlas is treated in an identical manner.
ture is between one-half and one bone diameter away from Each anatomic area is divided into four equal zones. Palpable
the bone on its opposite side. It is wise to insert such pins bony landmarks identify the upper and lower limits of each
under radiographic or uoroscopic control. A pin is also anatomic area under consideration.
considered a danger pin if it must be inserted adjacent to In the thigh, the proximal bony landmark is the lateral
a neurovascular structure on the near side of the bone. prominence of the greater trochanter of the femur; the distal
Generally this requires open pin insertion—a longitudinal landmark is the lateral prominence of the lateral epicondyle
incision to identify the location of the structure before pin of the femur.
insertion. In the lower leg section, the proximal landmark is the
Pin placement is measured in degrees, rotating around medial tibial joint line; the distal landmark is the medial
the bone from anterior to posterior, with the center of the prominence of the medial malleolus.
bone always presumed to be the center of pin placement. In the upper arm, the proximal landmark is the lateral
Thus the direct anterior position is considered to be 0 degrees, prominence of the greater tuberosity of the humerus, which
and the direct posterior position is considered to be 180 is one thumb’s width below the lateral tip of the acromion
degrees. Pin placement from directly lateral to directly medial process. Distally, the landmark is the lateral epicondyle of
is considered to be 90 degrees lateral and a pin placed from the humerus.
directly medial to directly lateral is considered to be 90 degrees In the forearm, the proximal landmark is the lateral
medial. In the forearm where there are two bones available prominence of the radial head, which is one thumb’s width
for pin placement, the pin position for each is noted sepa- distal to the lateral epicondyle of the humerus. The distal
rately. The limb must be in the anatomic position during landmark is the lateral prominence of the radial styloid
pin insertion if the atlas is to be used correctly. The humerus process.
should be in neutral rotation, and the forearm supinated to
correlate with the location of the anatomic structures
TECHNIQUE OF IDENTIFYING LANDMARKS
indicated.
I recommend image intensication uoroscopy for pin Each limb segment in the atlas is divided into four zones
or wire insertion. The correct assessment of the position and that are labeled A, B, C, and D, with A proximal and D
depth of the pin can best be determined if the pin is seen distal (Fig. 8.8). The zones approximate, but are not exactly,
in its true lateral projection. (In the true lateral projection the quarters of each limb segment. The atlas illustrates
of the pin, the central beam of the x-ray tube must be per- cross-sectional anatomy in the top, middle, and bottom of
pendicular to the pin itself.) At times, there is a tendency each zone. Key diagrams on each plate orient the reader to
by surgeons to judge pin position through use of an oblique the zones illustrated. For purposes of clarity, bones, nerves,
projection because a true lateral projection of the pins is arteries, and veins have been emphasized in relief. Muscle
difcult to obtain when the patient is supine on a large planes are indicated, but the muscle masses themselves are
operating table. The surgeon may have to use considerable not labeled. Small cutaneous nerves, veins, and muscular
ingenuity to position a limb for uoroscopy with a C-arm branches of arteries have been omitted. Major arteries are
image intensier. It may be necessary, for example, to rotate shown with one vein even if they are usually accompanied
the limb 45 degrees or more, while rotating the C-arm in by two venae comitantes. In the forearm, deep veins have
the opposite direction to obtain a true lateral projection. To been omitted completely. Some neurovascular structures
determine the exact location of a pin within a bone, it is are emphasized by making them slightly larger than
necessary to direct the central beam of the x-ray tube along natural size.
the pin itself. A perfect axial projection of the pin will result Many structures are labeled only once on each page, rather
in a small circular image equal to the diameter of the pin. than on each slice. Mental reconstruction of the zone will
In this manner, the position of the pin relative to the cortices ll in labels on the unlabeled slices. Unfortunately, some
can be determined. If roentgenograms rather than uoroscopy anatomic features are not easily presented in cross-sectional
are used, the initial evaluation can be obtained after the rst views. These are the transverse vessels and nerves that wind
pin is inserted to the presumed proper depth. Before the around the bone at one level. Furthermore, the atlas plates
roentgenogram is taken, it is safer to be too shallow than do not take into account variations in anatomy that can
too deep. If a pin is inserted too deeply, there is the obvious occur at any level. For these reasons, the atlas illustrations
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216 Section one — General PrinciPleS
PATHOPHYSIOLOGY OF PIN- OR
WIRE-SITE SEPSIS
O.R. Towel FLUID SECRETION
A metallic pin—or most hard foreign substances for that
matter—when inserted into the body’s tissues will provoke the
development of a membrane separating the foreign material
from the adjacent tissues. If relative motion is present between
the foreign material and the local tissues, a bursal membrane
usually forms to secrete lubricating uid. With a transcutane-
ous pin, however, the bursal uid becomes contaminated
with microorganisms through the pinhole. Nevertheless, the
1 contamination presents no special problem as long as the
2
pinhole drains freely to the outside. Pinholes become infected
when the delicate balance between the patient’s natural
defenses and the bacteria’s infective capability changes. This
alteration can result from (1) the development of an abscess
(closed space) around the pin; (2) the presence of necrotic
tissue in the pinhole, which can become the focus of sepsis;
A B C D and (3) the presence of excessive motion between a pin and
adjacent tissues, which increases uid production.
1
4
ABSCESS FORMATION
As noted earlier, the uid formed around the pin by the
local tissues drains to the external surface and is contaminated
Fig. 8.8 To mark the zones, stretch a surgical towel between the with microorganisms in the process. The amount of uid
proximal and distal landmarks described in the text and mark the may be limited, especially when there is no motion between
position of the landmarks on the towel with a surgical pen. Fold the soft tissues and the implant, such as over the anterior
the towel so that the marks touch each other and mark the midpoint
tibia. The uid dries on the surface, forming a crust. If this
of the fold. Lay the towel against the limb again and mark the midpoint
on the limb using the towel as a guide. In this manner, the limb section
crust restricts free drainage of the contaminated bursal uid
will be divided in half. Repeat the procedure and nd the midpoint of by sealing the pinhole, deep abscess formation may result.
each half, thus dividing the limb segment into four equal zones. Thus frequent pin care directed toward removal of the crust
from the pin–skin interface reduces pin sepsis.
SKIN NECROSIS
must be considered schematic, rather than representational Necrosis of the skin will occur if the tension (or compression)
(Figs. 8.9–8.27). produced by the pin interferes with the circulation of the
local subdermal capillary plexus. Plastic surgeons are mindful
of this principle when transposing skin aps; trauma surgeons
PIN TRACT INFECTION using transcutaneous pins for external skeletal xation must
also keep it in mind. Skin tension can occur immediately
Pin tract infection has always been the principal drawback after implant insertion or whenever a change in alignment
to the use of external xation. Unfortunately, preliminary or length is made. Skin can also be pinched between pins
communications announcing the development of new xators or wires if they are too close together.
rarely take note of this complication. Subsequent reports of
external xator applications, however, provide evidence that HEAT INJURY
pin tract infections continue to plague these devices.48–52 Thermal damage to skin and soft tissues occurs when a
One problem in determining the overall incidence of pin high-speed drill bit becomes hot while passing through hard
tract infections is that different authors use different sets of cortical bone, burning tissue as it emerges from the opposite
criteria to dene pin tract infection. This variance is present side of a bone. Avoid heat buildup by using a stop/start
even within a single institution, making a review of patients’ Text continued on p. 235
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cHaPter 8 — PrinciPleS and comPlicationS of external Skeletal fixation 217
Thigh, Zone A
Tuberosity of ischium
Lat. femoral
cutaneous n.
Br. of obturator n.
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218 Section one — General PrinciPleS
Thigh, Zone B
Greater saphenous v.
Deep femoral a. & v.
Post. femoral
cutaneous n.
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cHaPter 8 — PrinciPleS and comPlicationS of external Skeletal fixation 219
Thigh, Zone C
Greater saphenous v.
Sciatic n.
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220 Section one — General PrinciPleS
Thigh, Zone D
Popliteal a.
Popliteal v.
Saphenous n.
Greater saphenous v.
Tibial n.
Common peroneal n.
Lat. sural cutaneous n.
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cHaPter 8 — PrinciPleS and comPlicationS of external Skeletal fixation 221
Leg, Zone A
Saphenous n.
Deep peroneal n.
Superficial peroneal n. Greater saphenous v.
Tibial n.
Medial sural cutaneous n.
Lesser saphenous v.
Anterior tibial v. & a.
Peroneal a. & v.
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222 Section one — General PrinciPleS
Leg, Zone B
Greater saphenous v.
Saphenous n.
Deep peroneal n.
Anterior tibial v. and a.
Posterior tibial a. & v.
Superficial peroneal n.
Tibial n.
Fibula
Medial & lateral
sural cutaneous n.
Lesser saphenous v.
Peroneal
a. & v.
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cHaPter 8 — PrinciPleS and comPlicationS of external Skeletal fixation 223
Leg, Zone C
Tibial n.
Peroneal a. & v.
Sural n.
Lesser saphenous v.
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224 Section one — General PrinciPleS
Leg, Zone D
Anterior tibial
v. & a.
Peroneal
a. & v.
Deep peroneal n.
Greater saphenous v.
Lesser saphenous v.
Sural n.
Achilles tendon
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cHaPter 8 — PrinciPleS and comPlicationS of external Skeletal fixation 225
Foot
Flexor hallucis
longus
Plantar
arch Abductor hallucis
Lat. plantar n.
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226 Section one — General PrinciPleS
Coracoid process
Scapula
Suprascapular n.
transverse Musculocutaneous n.
scapular a. & v.
Median n.
Radial n.
Axillary n.
Cephalic v.
Circumflex
scapular a. & v.
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cHaPter 8 — PrinciPleS and comPlicationS of external Skeletal fixation 227
Arm, Zone B
Radial n.
Musculocutaneous n.
Median n.
Brachial a. & v.
Cephalic v.
Basilic v.
Ulnar n.
Deep brachial a.
Radial n.
Medial head
of triceps
Radial n.
Fig. 8.19 Arm, Zone B. Anatomic Considerations.
1. The brachial artery and veins and the brachial plexus remain medial to the humerus in this zone.
2. The radial nerve separates from the main neurovascular bundle and passes posterior to the humerus in zone B, separated from the bone
by the medial head of the triceps.
3. The musculocutaneous nerve and cephalic vein are anterior to the humerus in zone B.
Pin Placement
1. Half-pins from 90 degrees lateral must be accomplished with caution in midzone B because of the position of the radial nerve medial to the
humerus.
a., Artery; med., medial; n., nerve; v., vein.
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228 Section one — General PrinciPleS
Arm, Zone C
Ulnar n.
Radial n.
Cephalic v. Ulnar n.
Radial n.
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cHaPter 8 — PrinciPleS and comPlicationS of external Skeletal fixation 229
Arm, Zone D
Ulnar n.
Median n.
Cephalic v.
Basilic v.
Lat. cutaneous n.
of forearm
Ulnar n.
Radial n.
Radial n.
Ulnar n.
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230 Section one — General PrinciPleS
Forearm, Zone A
Ulnar n.
Median n.
Basilic v.
Ulnar n.
Radial n. deep br.
Radial a. & v.
Common interosseous
a. & v.
Median n.
Ulnar a. & v.
Radius
Ulna
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cHaPter 8 — PrinciPleS and comPlicationS of external Skeletal fixation 231
Forearm, Zone B
Cephalic v.
Med. cutaneous n. of forearm
Median n.
Ulnar a.
Ulnar n.
Basilic v.
Lat. cutaneous n. forearm Radial n. & a.
Radius Ulna
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232 Section one — General PrinciPleS
Forearm, Zone C
Ulna
Median n.
Ulnar n.
Radius Ulnar a.
Basilic v.
Post. interosseous a.
Radial a.
Cephalic v.
Radial n.
Ext. carp. rad. longus
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cHaPter 8 — PrinciPleS and comPlicationS of external Skeletal fixation 233
Forearm, Zone D
Radius
Ulna
Ulnar a.
Radial a. Ulnar n., volar br.
Basilic v.
Radial n.
Median n.
Cephalic v.
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234 Section one — General PrinciPleS
Hand
Median n.
Ulnar a., superficial br.
1st volar
metacarpal a.
Pelvis
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cHaPter 8 — PrinciPleS and comPlicationS of external Skeletal fixation 235
BONE NECROSIS
Necrosis of bone can occur with the heat generated from
drilling. Damage to osteocytes occurs after exposure to
temperatures of 55°C (131°F) for 1 minute or more. Indeed,
the mechanical properties of cortical bone change when
exposed to temperatures of 50°C (122°F) or more.53–55 The
best way to prevent heat buildup is to predrill bone holes
with a sharp drill bit, cooled with irrigation uid, followed
by the hand insertion of the implant.
Because each pinhole provides a continuous portal of
entry for bacteria into the bone, heat-damaged bone is more
likely to become a focus of chronic infection than is normal
bone.
Excessive bone pressure—due to compression of a frame—
may cause necrosis of osseous tissue at the pin–bone interface.
The pressure reduces local bone circulation, resulting in
death of osteocytes; necrotic bone may become the focus of
a chronic infection.
MOTION
Relative motion between a pin and adjacent tissues contributes
to pinhole sepsis. As far as the microenvironment of the
Fig. 8.28 Irrigate the drill bit while drilling to cool it. pinhole is concerned, it makes little difference whether the
pin is moving with respect to the tissue or the tissue is sliding
back and forth along the pin. The effect is the same, which
is relative motion between soft tissue and a contaminated
foreign body (the pin). Reduction of motion at the pin–tissue
interface decreases the incidence of pin tract infections. (The
low incidence of pin tract infections in reported series of
fractures managed with pins-in-plaster is due, no doubt, to
skin immobilization by the plaster cast.)
The Pin–Skin Interace
Wherever possible, reduce motion between the pin and soft
tissues by selecting areas for pin insertion that avoid muscle
transxion. Further reduction in soft tissue/implant motion
can be accomplished by wrapping the pins with a bulky wad
of gauze dressing between the skin and the xator.
Recognizing that implant-site sepsis usually starts at the
pin–skin interface (rather than the pin–bone interface) has
led some researchers and clinicians to try to reduce the
Fig. 8.29 The bayonet point of an Ilizarov wire can twist soft tissue, infection rate associated with external xation by coating
causing necrosis. the shaft of pins and wires with a known bacterial inhibitor,
specically, silver or tobramycin.56–60
Silver-based antiseptics are being employed in everything
from neonatal eye drops to burn ointments. Although initial
drilling rhythm and irrigating the drill sleeve while drilling experimental studies suggested that silver coating of pins
(Fig. 8.28). could reduce infections in vitro60 and in a sheep iliac crest
model,57 a subsequent human trial revealed no difference
DEEP SOFT TISSUE NECROSIS in infection rate.56 Moreover, the presence of free silver in
Necrosis of deeper soft tissues develops when tissues are the serum of patients in the silver-coated pin group caused
compressed by an implant after it has been inserted. Such the researchers to terminate the study and recommend against
tension occurs in the anterior compartment of the lower leg the continued use of such implants, effectively eliminating
if a pin pushes the anterior compartment musculature further development with such devices.58
posteriorly. (It is far wiser to transx the muscle by pushing The effectiveness of the antibiotic tobramycin against both
the pin straight in, thereby avoiding undue tension.) Necrosis staphylococci and gram-negative rods suggested that local
may also be produced if soft tissue “winds up” around a application of the medication might reduce pin-site sepsis
spinning implant or drill bit. (This can best be prevented for transcutaneous implants. Unfortunately, tobramycin cannot
by the use of a sleeve for both drilling and pin insertion.) be coated directly onto metallic pins with any predictable
Smooth wires will not likely wind up soft tissues, although a elution, so tobramycin-impregnated methylmethacrylate pin
spinning bayonet point might do so (Fig. 8.29). sleeves were developed59 employing the antibiotic-cement
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236 Section one — General PrinciPleS
combination used for total joint replacement or formed into extends for many centimeters around the pinhole (a common
beads for the treatment of osteomyelitis. As with silver coatings, phenomenon when stainless steel pins are employed) occurs
the tobramycin-acrylic sleeves failed to deliver the expected rarely, if at all, with titanium implants.
benet. Indeed, it seemed to some clinicians that the infection The only drawback to the use of titanium pins (aside from
rate increased when tobramycin sleeves were used. A reason- their higher cost) is their reduced stiffness compared with
able explanation for this observation is that the tobramycin stainless steel pins. Although in some situations, such exibility
is eluted from the surface of the pins for a very limited might be desirable, most surgeons prefer stiff xator-pin-bone
amount of time, with antimicrobial levels surrounding tissue congurations, especially when bone fragments must be
dropping off rapidly a few days after implantation. Although moved by the xator to correct deformities. For this reason,
the initial high concentration of tobramycin may sterilize a researchers and manufacturers searched for a way to retain
closed space such as a cavitary osteomyelitis or a joint replace- stainless steel’s stiffness yet reduce the likelihood of implant
ment, a pin sleeve, constantly exposed to fresh bacteria on loosening. The result was HA-coated threads of stainless steel
the skin surface, may function as a contaminated foreign pins.55,75,76
body perpetuating the infection once the antibiotic has HA, the mineral of bone, is applied via an expensive but
leached out of the cement. reliable ion-plasma coating technique to the surface of stain-
less steel pins to permit osteointegration of the patient’s
The Pin–Bone Interace bone with the implant to reduce loosening. In a 1997 prospec-
Pin loosening contributes to the development of pin tive randomized study using a sheep model,75 Italian research-
tract infections. Hyldahl et al.,61 Perren,62 and others51,63 ers found that local pin-site osseous rarefaction was signicantly
studied the pathophysiology of loosening hardware within lower—and extraction torque signicantly higher—when
bone. They noted that bone resorption and subsequent HA-coated pins were compared with uncoated pins. Five
implant loosening results from cyclic (rather than con- years later, German researchers conducted a similar project
stant) pressure at the bone–metal interface. Once a pin with human patients, comparing titanium pins with HA-coated
becomes loose, pin–tissue interface motion will promote pins.76 They found a fourfold difference in extraction torque
sepsis in a manner consistent with mechanisms already in the coated-pin group and a marked reduction in pin-site
described.51 sepsis as well.
Employing only threaded pins can decrease motion at the Conversely, Pizà and coworkers in Spain compared HA-
pin–bone interface. If properly inserted, they will not slip coated pins to uncoated pins in a group of patients undergo-
back and forth in the bone as will smooth pins. Threaded ing limb elongation for stature increase.77 Although they
pins, especially tapered threaded pins, should not be “backed found a 20-fold decrease in pin loosening in the coated-pin
out” once they are inserted, as they tend to loosen more patients, the incidence of pin-site sepsis did not differ between
quickly thereafter. the two groups.
Another way to reduce cyclic pin motion is to increase Thus it appears that HA coating on pins, whether studied
the stability (stiffness) of the xator conguration. Briggs in animals or humans, signicantly reduces implant-site
and Chao64 and others65–71 determined that xator stiffness loosening but may not decrease pin-site sepsis, except perhaps
can be increased by (1) increasing the number of pins; (2) in those situations where the infection is associated with
increasing the distance between the pins within each pin osteolysis and loose pins.
cluster; (3) applying pins closer to the fracture site; and (4) In our own clinical experience, the osteointegration associ-
incorporating pins that are mechanically stiff into the xator. ated with either HA-coated steel pins or biologically inert
The problem of xator stability becomes critical if one or titanium pins makes it almost impossible to remove threaded
more loose pins must be removed for sepsis. Loosening of external xation pins from cortical bone in awake patients.
the remaining pins may occur as the overall stiffness of the Injecting local anesthetic into or around the pin site does
frame conguration decreases. These difculties can be not help reduce the intolerable pain associated with trying
avoided in the rst place if a sufcient number of pins are to break loose an osteointegrated pin; instead, general
inserted to allow removal of one or more pins without affecting anesthesia is used for xator removal when bone ingrowth
the integrity of the xation. As Naden stated, it is “better to pins have been used.
add a pin than to have one too few.”72 Clearly, modern technology has improved the longevity
Certain recent developments have helped reduce the inci- of external xation with threaded implants, diminishing both
dence of pin tract infections caused by loosening, including late loosening and those infections associated with osteolysis
the use of titanium—rather than steel—pins, and hydroxy- and diminished xation. However, as previously mentioned,
apatite (HA)–coated threads (usually applied to steel pins). early soft tissue pin- or wire-site sepsis has not responded
The use of pins made from a titanium alloy rather than favorably to antibiotic- or antiseptic-coated implants. Instead,
stainless steel results in a reduction in implant-site sepsis (as surgeons must resort to the time-honored methods of eliminat-
observed with other orthopaedic implant systems, including ing tissue necrosis at the time of pin or wire insertion, as
total joint implants and intramedullary nails).73 The toxic effect well as those techniques that stabilize the implant–skin
of steel on cellular function may be related to the elution of interface once the device is in place.
certain metallic ions—perhaps nickel or chromium—from
the implant’s surface. Titanium pins reduce the incidence STRATEGIES TO REDUCE IMPLANT-SITE SEPSIS
of pin tract infections by about 50%.74 Moreover, it has been
noted that when implant-site infections do occur around FIXATOR SELECTION
titanium pins, the problem stays localized to the immediate The selection of the appropriate xator construct is particu-
environment around the implant. Extensive cellulitis that larly important. In general, the conguration should be quite
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cHaPter 8 — PrinciPleS and comPlicationS of external Skeletal fixation 237
stiff. This feature alone will do much to prevent pin sepsis.51,77 When drilling, stop the drill every few seconds to allow
When dealing with a chronic bone infection or an extensively the cutting tip to cool. The heat generated by drilling not
contaminated wound, the xation frame should be capable only damages the bone, but also “work-hardens” osseous
of extraordinary rigidity. If the orthopaedic problem is less tissue, which then resists further advancement. A worthwhile
complex and the application short term, a less rigid congura- practice is to irrigate the drill bit to cool it and conduct heat
tion will do. If planning a secondary surgery while the xator away from the tip.
is in place, select a frame conguration with the contemplated If much resistance is encountered during drilling, check the
procedure in mind. If comminution of fracture fragments drill-bit tip between your ngertips for excessive temperature.
is present, the frame should permit control of intermediate If the tip cannot be comfortably held for 15 or 20 seconds, do
fragments. Because it is better to insert pins through intact not leave an implant in the bone hole, as there will be necrotic
skin, the xator should permit pin placement to be dictated (thermally injured) bone in communication with the pin’s
by the nature of the injury rather than by the conguration bacteriologic environment—a setup for chronic osteomyelitis.
of the frame. Instead, insert the pin (wire) elsewhere. Likewise, the bone
in the drill bit’s utes should be white, never black or brown,
PIN SELECTION which are signs of burnt bone (Fig. 8.30).
Smooth pins: Smooth pins should not be used for external
skeletal xation. They create two holes in the bone but do PIN INSERTION
not offer the advantage of “screwed-in” bone xation. The Use a manual handle for pin insertion, which should be
unfortunate experience with the Stader and Anderson devices accomplished through the drill sleeve. Avoid overinsertion.
in the 1940s was due, I believe, to insufcient xation with
smooth pins. Inserting Transfxion Wires
Threaded pins: Both cylindrical and tapered-thread pins As with pins, avoid tissue necrosis when inserting wires, which
are available with or without the HA coating.63 Most knowl- can be caused by either wrapping up of tissues, excessive
edgeable surgeons prefer the coated pins, although there is tension, or thermal injury from heat buildup during drilling.
no clear consensus about which thread shape works best. With transxion wires, a spinning bayonet point may wind
Some pins are both self-drilling and self-tapping, but such up soft tissues, causing necrosis. Therefore push transxion
implants have fallen out of favor with most surgeons, who wires straight through the tissue to bone before turning on the
prefer to predrill each pin site. drill. If the wire misses the bone, withdraw it completely and
reinsert it rather than redirecting it within the limb’s tissues.
When inserting transxion wires into bone with a power
PIN AND WIRE INSERTION CONSIDERATIONS
drill, the dense cortical bone, by offering substantial resistance
Fracture Alignment to the wire point’s progress, may cause heat buildup, which
Align the fracture as precisely as possible before pin insertion. hardens the bone even more, resisting additional progress
An unaligned fracture will create undue tension (a source of the wire point. For this reason, stop the drill every few
of possible necrosis) by the skin on the concave side of the seconds with a stop–start action to advance a wire slowly
fracture deformity when the fracture is reduced. The pins through hard osseous tissue
or wires may also pinch the skin on the convex side of the When inserting a transxion wire with a motorized chuck,
fracture deformity, creating additional skin necrosis. Moreover, wire exibility may, at times, cause the wire to bend, reducing
some xators require precise alignment of rotation at the accuracy of placement. For this reason, whenever inserting
fracture site before pin insertion because the frame does a wire, manually grasp the wire close to its tip to stabilize it.
not permit correction of axial malalignment once the pins
are in place.
Predrilling
Inserting a self-drilling stainless steel pin into the tibia of a
young healthy adult male can be an exercise in frustration
for the surgeon. After drilling for a while and making no
headway, there is a tendency to push harder and turn the
drill faster. Heat (from drilling) increases the microhardness
of bone, making progress difcult.53 To make matters worse,
the cuttings (chaff) from the drilling of bone have no place
to go because the pin contains no uting (groove). The
chaff also increases friction, making the drilling even more
difcult. Friction created by these factors increases the
temperature of the pinpoint until it is too hot to touch when
it emerges from the opposite side of the limb. It is easier
(and safer) if the surgeon predrills cortical bone through a
drill sleeve before pin insertion. A sharp drill bit will penetrate Fig. 8.30 Bone in the utes of a drill bit should be creamy white in
bone more easily than will a pointed pin because the uting color. Any brown or black spots on the bone’s surface indicate that
of the drill bit permits the chaff to be carried away from the the bone was burned during drilling. Such a bone hole should never
worksite, reducing friction and also the amount of effort be used for external pin or wire xation, because the risk of osteomyelitis
required of the surgeon. is high.
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238 Section one — General PrinciPleS
Because a spinning wire can wrap up surgical gloves, hold • Penetrate muscles at their maximum functional
the wire with a wet gauze pad. length.
As soon as a transxion wire’s point penetrates a bone’s
far cortex, do not continue drilling because the spinning This last rule—critically important for a successful long-term
wire tip might damage tissues on the limb’s opposite side. application—means that the position of a nearby joint must
Instead, grasp the wire with pliers and hit the pliers with a change as a pin or wire passes through the exor and extensor
mallet to drive the wire through (Fig. 8.31). muscle groups. For example, when inserting a wire into the
A most important principle when using any transxion lower leg, plantarex the foot when transxing the anterior
implant: If the tip of a wire (or pin) emerges from the opposite compartment, invert the foot when inserting wires into the
side of a limb either smoking, or too hot to be comfortably peroneal muscles, and dorsiex the foot during triceps surae
held between the surgeon’s ngertips, the wire should be impalement.
withdrawn, cooled, and reinserted elsewhere.
FRAME ASSEMBLY
Implant–Skin Interace Management Frame assembly can be extremely time consuming if the
After inserting a wire or pin, but before attaching it to the surgeon is not familiar with the technical details necessary
frame, check the skin interface for evidence of tissue tension for constructing the proper spatial conguration of the xator.
while the limb is in its most functional position—that is, with It is important to practice frame assembly before surgery. A
the knee extended, the ankle at neutral, and so forth. Interface piece of wood or synthetic bone can be used. Learn the
tension will create a ridge of skin on one side of a wire or correct names for the components, asking for them as one
pin. Incise the ridge to enlarge the skin hole around either would ask for any surgical instrument. The OR personnel
a transosseous pin or an olive wire. Close the enlarged hole will quickly learn the names of the components if they are
with a nylon suture (if necessary) on the side of the wire expected to hand them to the surgeon.
opposite the released ridge. Once the frame is assembled, skeletal alignment should
When the ridge of skin is adjacent to a smooth wire, be evaluated with roentgenograms or uoroscopy. Some
slowly withdraw the wire (with pliers and a mallet) until
its tip drops below the skin surface. Allow the skin to shift
to a more neutral location and advance the wire again
until it passes through the skin in an improved position
(Fig. 8.32).
If the interface tension exists on the insertion side of
a limb, snap off the wire’s blunt end obliquely to create a
point and advance the wire to just below the skin surface
by the pliers–mallet method on the limb’s far side. Tap
the wire back through the skin after making a position
adjustment.
With either transxion wires or pins, check the range of
motion to make sure that no undo tension occurs during
the anticipated movement required while the xator is on
the limb. If necessary, an implant should be reinserted if
movement of an adjacent joint causes skin tension.
Certain important techniques of transxion-wire inser-
tion ensure maximum functional limb use and joint
mobility:
Fig. 8.31 Use a mallet to drive a wire through soft tissues on the
• Avoid impalement of tendons. opposite side of the limb, thereby reducing the risk that a spinning
• Avoid (whenever possible) transxing synovium. bayonet pit will damage soft tissues.
A B C
Fig. 8.32 (A) A wire can cause skin tension as it emerges (white arrow). (B) Withdrawing a wire causes skin tension and allows the skin to
shift to a more neutral position. (C) Push the wire forward through the skin in the new location with a mallet and pliers. The black arrow points
to the original wire position in the skin.
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cHaPter 8 — PrinciPleS and comPlicationS of external Skeletal fixation 239
projections will be difcult to interpret because of the management consists of rest with elevation of the affected
presence of radiopaque components of the xator. If this limb. The frequency of cleansing around the pinhole should
occurs, oblique projections can be obtained of both limbs be increased. I may enlarge the skin hole by inltrating
(for purposes of comparison). If alignment is unsatisfactory, the skin around the pin with a local anesthetic, and then
the entire frame should be loosened and a manual correc- insert a size 11 blade into the skin adjacent to the pin. I
tion of the limb carried out. The frame should not be used also start the patient on oral antistaphylococcal antibiotics.
to correct malalignment of a fracture by compressing the If these measures fail to promptly relieve the problem, the
convex, and distracting the concave, side of the fracture pin clamp should be opened slightly and the pin checked
deformity. for loosening by wiggling it. If the pin is loose—or if the
maneuver produces pain—the pin should be removed. If
PIN CARE ROUTINE removal of the loose pin affects the stability of the xator, a
As noted earlier, it makes little difference to the pinhole new pin must be inserted in another location. The pinhole
microora whether the pin is moving in the soft tissues or should be curetted with a small curette after a septic pin is
the tissue is sliding along the pin; the effect is the same, removed. If, however, an infected pin is securely fastened
which is relative motion between the tissue and a contaminated to the bone, the patient should be admitted to the hospital
foreign body. Reduction of soft tissue motion around the for a brief course of parenteral antibiotics, bed rest, and a
pinhole can be accomplished by forming a bulky wad of deep incision and drainage of the soft tissues around the
gauze dressing wrapped around the pin to completely ll pinhole. Antibiotic therapy can be guided by cultures of the
the space between the skin and the xator. This controls implant site. If the septic process is not resolved by these
sliding of the skin when the limb swells, after ambulation or actions, the involved pin should be removed and replaced
activity. with a new one in a different position. If the infection does
The question of daily pin care stirs much controversy among not involve the bone, drainage should stop in a few days.
workers in the eld of external skeletal xation. My routine If draining persists, there is a signicant probability that
for pin care consists of daily cleansing of the pins and sur- the patient has developed a chronic implant-hole infec-
rounding skin with a soapy solution, using small swabs or tion, which will require curettage and perhaps even more
applicator sticks. If the patient is reasonably agile, he or she extensive care.
can wash around the pins with soap and water in the shower.
This is followed by application of an antibiotic ointment
(Neosporin or Bactroban), and then a bulky wrap—as FIXATOR-ASSOCIATED PROBLEMS
described earlier—to control the space between the skin and
the xator. It is a rare individual indeed who happily wears an external
In spite of diligent efforts, however, some pins will become skeletal xator. Patient-related problems caused by the frame
septic. Furthermore, pin tract infection, at times, seems to are pressure necrosis of the skin and undue or excessive
occur when least expected. A most carefully placed, thoroughly pain. Pin or wire breakage may occur while a xator is in
released, and well-managed pinhole may become infected place, causing distress to the patient and his or her surgeon.
while others in the same patient do not. Nevertheless, close Disruption of the patient’s lifestyle and psychosocial problems
adherence to the principles outlined in this chapter will do associated with external skeletal xation, generally related
much to control the factors primarily associated with pinhole to long-term application combined with protracted hospitaliza-
sepsis. tion, may occur.
Ambulatory Aids
PRESSURE NECROSIS
Because implant loosening is associated with sepsis, efforts
should be focused on reducing cyclic stresses at the implant– Continuous contact with the frame or one of its components
bone interface. Such stresses occur with unprotected weight will cause intense burning pain for several hours, followed
bearing in lower extremity applications. Therefore do not by ischemic necrosis of the tissues being compressed. This
permit patients to ambulate with a xator in place without usually leads to an infection and a worsening of the xator
supplementary ambulatory aids such as crutches (until the experience of all concerned.
bone consolidates). The reason for this is obvious. The The amount of clearance required between the skin
external xator serves as an exterior skeleton when there is and the xator varies from region to region. In the upper
no continuity of bone after a fracture. The mechanical stresses extremity, and in lower extremity applications where there
of weight bearing are transferred from the bone to the xator is bone immediately under the subcutaneous tissues (as in
at the implant–bone interface. The implants, being exible, the pretibial region of the leg), two ngerbreadths between
will transmit cyclic pressure associated with ambulation to the skin and the xator are sufcient. Three or more nger-
the bone. This results in bone resorption and subsequent breadths are required over most soft tissue areas in the lower
implant loosening. For this reason, unprotected early weight extremity where there is muscle between subcutaneous tissue
bearing with an external skeletal xator on the lower extremity and bone.
should be discouraged. If limb swelling is anticipated, additional clearance will
be necessary. Often more than three ngerbreadths are
DEALING WITH PINHOLE PROBLEMS required in the lateral aspect of the thigh in an obese
If the patient presents with evidence of pinhole sepsis after patient, because the soft tissues there bulge laterally when
application of an external skeletal xator, the surgeon the patient is lying down. When applying an external xator
should make every effort to resolve the problem. Initial to the pelvis, 10 to 15 cm clearance must be left for the
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240 Section one — General PrinciPleS
abdomen, so the patient can sit up. It is important to ll the require more narcotic medication for relief than do other
space between the skin and the xator with a bulky gauze patients.
wrap, to prevent excessive motion between the skin and the Pain around implant sites after surgery, though signicant,
implants. is usually overshadowed by the operative site symptoms.
However, if pain around an implant predominates among
the early postoperative complaints, inspect the site. Occasion-
BROKEN COMPONENTS
ally, pressure from these dressings against the skin can produce
Occasionally, pins break while the xator is on a patient. discomfort, not unlike the pressure from a snug-tting cast.
Chao and colleagues78 observed that static stresses on the The patient often complains of burning and can usually
pins of a xator applied without compression are 70 times specify the implant causing the problem.
greater than the stresses on the pins of a xator applied with Skin and soft tissue tension occurs with shifting of a mobile
compression because of the overall xator stability made by tissue area impaled by transcutaneous implants. As with a
the bone being compressed. Thus compression of the fracture too tight bulky wrap, tension on the skin at the implant site
site should be achieved if at all possible. produces pain or a burning sensation.
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cHaPter 8 — PrinciPleS and comPlicationS of external Skeletal fixation 241
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242 Section one — General PrinciPleS
A B
Fig. 8.33 The Ilizarov method can be employed to elongate a shortened limb (A) or to overcome a skeletal defect (B).
The moving bone fragment must, of necessity, be secured oblique and often combined with malalignment of the bone
to a mobile component of the xator, which slowly pulls the fragments in angulation, rotation, displacement (of the
fragment from its original position to its “docked” position mechanical axes), and shortening. When any or all of these
on the other side of the original gap (Fig. 8.33). In doing deformities are associated with a nonunion, circular external
so, the wires securing the fragment to the frame cut through xation permits the surgeon to gradually correct all deformi-
the skin and deeper tissues by a process that involves tissue ties, either simultaneously or in succession. With simple
necrosis and sloughing along the implant’s path, with healing, angular displacements, a hinged xator will prove sufcient
one hopes, on the trailing side. Thus in spite of advances in to solve the geometric problem, but for more complex
pin xation attributable to HA coating, pin-site infections malalignment involving multiple planes, the Taylor Spatial
are still a problem, especially when bone fragments are in Frame, although rather expensive, has proven invaluable. A
motion. Therefore meticulous attention to the principle surgeon interested in employing this modality should attend
outlined earlier in this chapter is even more important for a workshop on its use because many parameters of the
xator applications involving moving bone segments than deformity and frame conguration must be accurately
it is for frames applied for static purposes (see Fig. 8.33). determined and entered into a proprietary computer program,
Because this volume deals with trauma to the musculo- which produces a prescription for frame adjustment that the
skeletal system and its consequences, the following consid- patient uses to lengthen or shorten the frame’s struts.
erations apply to those situations in which bone fragments When an infection is present at the nonunion site, the
move with respect to one another, either for restitution of surgeon should thoroughly débride the infected bone—while
limb length and alignment or for lling in a defect created stabilizing the limb in an external xator—thereby converting
by traumatic loss of osseous tissue. the problem of an infected nonunion to an uninfected
nonunion. Reconstruction of the limb after débridement
TREATMENT PRINCIPLES FOR NONUNIONS usually involves intercalary bone transport if the débridement
has resulted in any substantial loss of bone tissue and a
AND MALUNIONS
segmental skeletal defect.
One fundamental difference between treating a nonunion
and a healed malunion is that with a nonunion, the site of
SEGMENTAL SKELETAL DEFECTS
any deformity correction (if needed) has been predetermined
for the surgeon, as the correction must usually be made Segmental defects may be due to either bone loss at the time
through the nonunion site. of trauma, removal of nonviable fragments at initial débride-
If the nonunion is transverse (perpendicular to the bone’s ment, or the result of resection of a tumor or necrotic infected
longitudinal axis), compression with external (or internal) bone. When a segmental defect is present, any angulation,
xation will stimulate union. Many nonunions, however, are rotation, translation, or combination of displacements can
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cHaPter 8 — PrinciPleS and comPlicationS of external Skeletal fixation 243
easily be corrected through the soft tissues at the level of A transport ring and an attached pair of crossed wires or
the defect. For this reason, circular frames designed to deal pins is the most stable way to pull a bone fragment through
with segmental defects are usually rather simple; the congura- tissue. Unfortunately, the wires cut through the skin and soft
tion is tubular, with the connecting rods of the frame parallel tissues as the ring and its attached bone segment move
to each other and to the bone’s biomechanical axis. through the limb. At the end of bone transport, however,
A skeletal defect can be overcome by Ilizarov’s bone the crossed transport wires enhance compression at the point
transport method (Fig. 8.34). The bone ends must be matched of contact between the intermediate fragment and the target
to t at nal docking of the intercalary fragment with the fragment.
target fragment. The target site is often bone grafted to When oblique directional wires are used to move a bone
hasten healing. With very large defects, it may be possible segment through a limb, there is far less cutting of tissues,
to perform two corticotomies and move the resulting bone because the wires start out nearly parallel to the limb’s axis.
fragments toward each other. Unfortunately, such oblique wires often do not provide enough
To eliminate the defect, make a corticotomy through pressure at the end of bone transport to ensure stable
healthy bone at some distance from the defect; thereafter, interfragmentary compression between the intermediate
the intercalary segment between the defect and the corti- fragment and the target fragment. For this reason, a surgeon
cotomy is pulled through the tissues until the defect is closed using oblique directional wires must often insert a pair of
and new bone forms in the distraction zone. The fragments crossed wires (connected to a ring) into the intermediate
should be perfectly aligned with the longitudinal elements fragment at the end of bone transport to enhance compression
of the xator. If this is not achieved, the transported fragment at the point of contact. In such a case, the patient would
will not meet up with the target fragment. require a second operation to insert the supplementary
If the defect is smaller than 1.5 cm, it is possible to compress compression wires.
the defect acutely (after appropriate débridement) and
lengthen the bone through a corticotomy elsewhere.
JOINT MOBILITY
It is unwise to acutely close a skeletal defect that is more
than 1.5 cm, as the redundant soft tissues surrounding the Intensive physiotherapy is also necessary to prevent the joint
defect tend to bulge out when the fragments are brought contractures and subluxations associated with limb elongation
together, creating an unsightly appearance to the leg and and the correction of deformities. Even if the xator is applied
kinking of both lymphatic and venous drainage. As this redun- to deal with a fracture or a nonunion—conditions not
dant skin is trapped between the wires, it cannot contribute ordinarily associated with stretching of tissues—irritation of
to lengthening of the limb through another section of the muscles impaled by pins or wires can lead to restriction of
bone. Therefore the patient is left with a peculiar-looking joint mobility. Thus physical therapy has an important place
limb with bulky redundant tissues at one level and tight, in the management of all patients in external xation.
stretched skin at another. With this problem in mind, when Whenever bone fragments are moved with respect to one
dealing with a segmental defect of more than 1.5 cm, it is another, soft tissues are placed under tension: the greater
better to leave the soft tissues at length, and eliminate the the movement, the greater the tension. For this reason, it is
defect by gradual transport of the intermediate segment. important for the surgeon to consider every Ilizarov xator
A segment of bone can be pulled through a limb with (1) application that involves movement of bone fragments as a
a transport ring and cross wires or pins or (2) with oblique form of limb lengthening, even if the extremity does not
directional wires. end up longer as a result of the procedure.
A B C D
Fig. 8.34 Infected intramedullary nail treated with débridement and bone transport. (A) Initial presentation. (B) At surgery, after removal of
nail, débridement of nonviable bone and proximal corticotomy. (C) During bone transport. Note the widening distraction gap and the narrowing
defect. (D) Oblique view demonstration cancellous autograft to create a tibiobular synostosis.
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244 Section one — General PrinciPleS
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cHaPter 8 — PrinciPleS and comPlicationS of external Skeletal fixation 245
By following the principles outlined in this chapter for both grafting is the hallmark of a well-thought-out treatment plan
Ilizarov and standard external skeletal xator applications, a wherein the surgeon recognizes the worrisome nature of the
surgeon will reduce the incidence of problems that might lead fracture pattern at the time of injury and prepares to bone
to an unpleasant experience for both patient and practitioner. graft the limb within the rst 6 to 8 weeks after the injury.
External xators have been condemned as nonunion machines An abundant body of trauma care literature has conrmed
because it seems that so many patients in trauma frames fail that certain strategies of initial management of severely injured
to heal their fractures (Fig. 8.35). There are several reasons extremities reduce the likelihood of serious complications,
for this observation: rst, xators are applied to the most while simultaneously enhancing the probability that the
severe fractures, those with a natural propensity toward patient’s functional outcome will be the best possible under
nonunion; second, with so-called spanning external xators, the circumstances.92
weight bearing or functional use is either very difcult or One of these strategies involves early coverage of exposed
precluded altogether. And third, patients are transferred tissues, either by delayed primary closure if enough local
(often for insurance reasons) to surgeons not familiar with soft tissue is available or coverage with transposed or trans-
the original treatment plan leaving a patient in a sort of planted soft tissue aps. Even though centuries of civilian
therapeutic limbo. and wartime experience have taught us the danger of primary
When applying an external xator to an acute injury, closure over devitalized muscle, bone, and adjacent soft tissues,
reduction of bone fragments must be as accurate as with we have also learned that prolonged exposure of any type
internal plate xation if the frame is to remain on the limb of tissue to the atmosphere invites microorganisms to move
during the entire treatment protocol. Suboptimal reduction in and establish long-term residence.93
might be acceptable with a temporizing xator when the A second strategy involves delayed denitive repair of
surgeon plans to soon remove the device and employ internal displaced fractures, with the goal of restoring fragments to
xation as the denitive form of stabilization. However, bear their original anatomic relationships without excessive
in mind that the best laid plans often go astray. Patients are devitalization caused by soft tissue dissection.94 Reduction
transferred after accidents to facilities where a new caregiver and internal xation of fractures, regardless of how carefully
may not be comfortable with the plan of the rst surgeon accomplished, causes reactive swelling of tissues. If such
and decides to continue the patient in the xator. The engorgement is superimposed on the swelling caused by the
suboptimal alignment then becomes the basis for tardy healing original traumatic injury, wound closure without tension
or results in a malnonunion requiring a difcult reconstruc- becomes difcult; excessive traction of tight soft tissues
tion effort. It is far better to strive for optimal alignment frequently leads to incision breakdown, necrotic wound edges,
when the frame is rst applied (unless circumstances preclude exposed hardware, bone, tendons, and soft tissues.
the time required to achieve this goal) and then deal with Waiting 7 to 14 days for swelling to diminish after a
any subsequent tardy union by bone grafting the troublesome traumatic injury before performing an open reduction and
region without the need for realignment. Indeed, early bone internal xation has become a hallmark of thoughtful
musculoskeletal trauma management.95 Although the early
healing during the 1- or 2-week waiting period may make
reduction of cancellous fracture fragments a bit more chal-
lenging (compared with the ease with which fresh fracture
fragments can be pushed around), the trade-off yields sub-
stantial reductions in postsurgical wound dehiscence and
thus a lower risk of infection.37
Third, unstable fractures, especially those associated with
signicant soft tissue damage, benet from mechanical
stabilization as soon as possible after injury. As patients are
moved around acute care facilities, on and off radiograph,
computed tomography (CT), and magnetic resonance imaging
(MRI) tables, to and from the operating suite, and into and
out of the intensive care unit, jiggling of fracture fragments
is not only intensely painful, but also macerates and may
even kill marginally viable soft tissues and especially skin of
questionable vascularity. Likewise, blood clots are disturbed
by undue tissue motion, and bleeding may resume after too
much movement. Finally, delicate surgical repairs of vascular
A B injuries are easily torn apart when limbs op around after
Fig. 8.35 Patient placed in external xator spanning the region of surgery.
injury. (A) The frame was left in place for 6 months without further Fourth, surgeons often nd it difcult to judge soft tissue
treatment. (B) Established nonunion with severe disuse osteopenia viability immediately after a catastrophic injury. At times,
and not a molecule of osteogenesis. tissues we thought were dead may truly be so, whereas in
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246 Section one — General PrinciPleS
other wounds, marginal soft tissue may survive unexpectedly. into the joint, or the joint itself may be severely damaged.
A “second look” return to the OR by patient and surgeon In either event, applying a temporizing external xator
24 to 48 hours after an injury is often the best way to judge stabilizes the osseous and soft tissues, preventing further
the viability of tissue remaining in the wound.94,96,97 damage and reducing pain.
The goal of limb stabilization in this context permits return
trips to the OR for repeated débridement without disruptive
THE TEMPORARY FIXATOR
manipulation of fracture fragments, a potential source of
further soft tissue injury. When an external skeletal xator is used as a temporizing
With these objectives in mind, the concept of temporary device, the frame conguration need not be as sturdy as
spanning external xators has evolved.97 During xator would be required for a more denitive application.96,98 As
application, precluding transcutaneous implants near the a general rule, patients who are so severely injured as to
region when subsequent internal xation is planned eliminates require a temporizing external skeletal xator as an early
the risk of pin- or wire-site sepsis contaminating the operative step in a protracted therapeutic strategy are rarely capable
eld of the open reduction and internal xation surgery of getting up out of bed and walking around with a xator
(Fig. 8.36). in place on a lower extremity. Likewise, for upper extremity
When the zone of injury scheduled for denitive internal applications, such individuals will not soon be bowling or
xation is limited to the middiaphyseal region of a long playing basketball.
bone, spanning external xation can often be applied to the Under the circumstances, temporizing external xators
same bone, with external xation limited to the ends of that usually consist of two half-pins secured to bone proximally,
same bone. This would be the ideal situation because freedom and two more half-pins inserted distally, with one or more
of movement of the adjacent joints would not be inhibited longitudinal rods connecting the proximal pin group with the
during the period of temporary external xation. Indeed, distal pin group. Typically, universal joint articulations connect
in such cases, it is also possible to convert a temporary external one rod to another when spanning a substantial distance.98
xator to a more permanent one and dispense with internal Pin-gripping clamps, typically incorporating universal joints,
xation altogether. completed the conguration. In many cases, one multihole
More commonly, however, joint involvement accompanies pin clamp is used for each pin cluster, although from a
injuries that lead surgeons to apply spanning external skeletal mechanical perspective, spreading out the pins in each
xation: Either the fracture lines of the diaphysis extend fragment and securing each pin to its connecting rod with
its own pin-gripper creates a more stable mounting.96
Specic strategies for timing of frame application, initial
and subsequent wound débridement procedures, soft tissue
management, antibiotic prophylaxis, anticoagulation, and
other general principles of trauma care are covered in detail
elsewhere in this volume. Likewise, operative techniques for
the reduction in xation of fractures and dislocations are
described in chapters organized by anatomic regions.
This section will emphasize concepts common to all xator
applications used as part of damage control orthopaedics,
whereby the conguration should be mounted in a manner
that affords access to the wound for additional therapeutic
measures and, wherever possible, allows denitive xation
without increasing the risk of deep sepsis caused by an earlier
pin-site infection.
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cHaPter 8 — PrinciPleS and comPlicationS of external Skeletal fixation 247
by either the spinning drill bit or the pin during insertion. xation for the femur, tibia, humerus, proximal ulna, and,
(Such tissue will be stripped of its blood supply and quickly when inserted obliquely, the distal radius as well.
become necrotic, a frequent cause of deep implant-site sepsis Fifth, although we recognize that a 50- to 60-mm thread
in the era before drill sleeves were part of the external xator length half-pin is usually desired for large cancellous bone
application protocol.) Therefore we recommend that such ends, using two 30-mm thread length (nonparallel) half-pins
drill sleeves be put in the eld kits. We realize that it requires in the distal femur or proximal or distal tibia/bula, one
three hands to use a manual drill and simultaneously press from each side, connected across the front of the limb with
a drill sleeve to the bone. Hence, when working alone, the bars, creates a stable triangular construct, which can be
operator can dispense with the sleeve. connected via additional longitudinal bars to the diaphyseal
Third, we recommend restricting the drill-bit selection parts of the frame.
to one size: 6 mm diameter smooth shaft stepped down Additionally, there are other challenges unique to this
to 5 mm uting diameter, 30 mm long. This will prevent setting. Patients injured during combat tend to have severe
overpenetration during drilling, which places neurovascular open wounds, and external xator pins should be placed
structures close to the bone’s far cortex at risk. outside of these wounds whenever possible.
Fourth, we propose employing only 6 mm diameter half- The accompanying cross-section atlas includes information
pins with a 30-mm thread length for diaphyseal bone applica- about certain pin insertion sites and directions where half-pins
tion in the eld. Such pins will not overpenetrate because can be inserted with low risk to nearby nerves, muscles, and
the end of the threads at the thread-shaft junction will prevent tendons. In the tibia, this is fairly straightforward, with pins
advancement in all but the most osteoporotic bone. In adults placed anteromedially along the face of the tibia being rela-
of combat age, a 30-mm thread length will provide bicortical tively safe (Fig. 8.37).
$ %
Fig. 8.37 (A) Safe zones for half-pin insertion into tibia (blue). (B) Surface anatomy demonstrating location of safe zones.
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248 Section one — General PrinciPleS
In the femur, anterolateral pin placement is ideal for knee without uoroscopy should be done with an open approach,
spanning and is easier for litter evacuation than straight using anterior iliac crest pins, and pins placed with ngers
lateral pins (Fig. 8.38). or instruments dening the inner and outer tables of the
Calcaneal transxion pins can also be placed safely, from pelvis.
lateral to medial to avoid the sural nerve branches, and
ensuring placement is posterior enough to avoid the medial
THE DRILL SLEEVE
plantar nerve branches (Fig. 8.39).
The upper extremity can typically be splinted in situations In noncombat situations, regardless of the availability or lack
where uoroscopy is unavailable, and placing external xation thereof of sophisticated OR equipment, whenever threaded
is normally not warranted. In the event temporizing external implants are used for external skeletal xation, a drill sleeve
xation is needed in eld situations where uoroscopy is should be employed for pin insertion. Ideally, predrilling
not available, the surgeon should avoid overpenetration of the bone hole with a sharp drill bit is desirable but not
the bone’s far cortex with either the drill bit or implant, and absolutely necessary if the implant itself has a cutting tip and
avoid inserting any transcutaneous implant in the lower half utes to carry away the bone dust generated while the hole
of the upper arm where the radial nerve is in intimate contact is being made. Even in this situation, however, where no
with the humerus. high-speed drill bit is used, a drill sleeve is essential. Without
The pelvis similarly can be stabilized with binder or sheet a sleeve, drill bits and, to a somewhat lesser extent, threaded
application, and external xation should be delayed until it pins wrap up soft tissues during insertion. This action strips
can be applied with uoroscopic guidance. In the rare instance the tissues from their blood supply, creating necrotic material
where there will be a signicant delay in moving the patient in the implant site, necessary pablum for microorganisms.
to higher level of care, or when severe open wounds preclude Indeed, the single measure that increased acceptance of
binder or sheet compression, pelvic external xation applied external skeletal xation by orthopaedic surgeons in the
$ %
Fig. 8.38 (A) Safe zones for half-pin insertion in the femur (blue). (B) Surface anatomy demonstrating location of safe zones.
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cHaPter 8 — PrinciPleS and comPlicationS of external Skeletal fixation 249
CHOICE OF IMPLANTS
A substantial reduction in pin-site sepsis occurred when
titanium pins were introduced. Osseous integration at the
pin–bone interface reduced early implant loosening, a precur-
sor to pin-site sepsis. Likewise, coating a pin’s threads with
an osteoconductive substance, specically calcium HA,
regardless of the metal, further diminished the incidence of
implant site sepsis.76,103–106
Each advance in the external xation pin technology
appears to enhance the potential longevity of a xator
application. However, every improvement seems to increase
the cost of the transcutaneous implants.
For temporizing external xation, where device removal
is expected 2 or 3 weeks after mounting, costly transcutaneous
pins are not necessary, because the benet of titanium pins
or coated pins does not become a critical factor in reducing
pin-site sepsis unless the frame has been on for several months.
A Therefore when applying a temporizing external skeletal
xator, low-cost stainless steel pins will do.
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250 Section one — General PrinciPleS
the rst two or three turns of the thread are of smaller vessel structures are at risk regardless of the method used
diameter than the rest (or incorporate cutting utes) and to secure the frame to the bone. In several locations, a nerve
thus do not grip the bone very well, if at all. or vessel lies directly on the surface of a bone where it is
easily injured. In other instances, nerves or vessels traverse
USING THE ATLAS FOR DAMAGE CONTROL a limb perpendicular or oblique to its longitudinal axis,
making it vulnerable to injury. The following structures are
ORTHOPAEDICS
of particular importance in this regard.
The pin locations and the directions in the accompanying Deep to the femur, however, laying along its posteromedial
cross-sectional atlas have been selected to allow for safe pin side, is located the deep femoral artery, a structure that
insertion even if the threads protrude beyond the far cortex. provides transverse feeder vessels to the thigh muscles. More
Thus if a pin in the atlas is designated “safe” (indicated important, the supercial femoral artery, in the midthigh,
by blue color), it can usually be driven all the way through is one of bone diameter away from the femur in its coronal
the limb and out the opposite side without risk of nerve or plane. A surgeon inserting pins into the lateral cortex of the
vessel injury, provided that the location and direction are as femur should avoid overpenetration, a possible source of
indicated. true or false aneurysms, both of which have been created by
In the accompanying atlas, when a nerve, vessel, or tendon external xation pins and wires. Limiting thread length to
is on the opposite side of the limb from pin insertion, but 25 or 30 mm should prevent damage to these structures, for
the distance exceeds one bone diameter, the level and direc- reasons explained earlier.
tion of insertion is designated “caution” (indicated by yellow
color). And if any nerve, muscle, or tendon on the opposite FEMUR
side of the limb from pin insertion is less than one bone The entire shaft of the femur is generally safe for pin insertion
diameter on the opposite side of the limb from insertion, from lateral to medial in the coronal plane of the body. The
the level and direction of implant insertion is designated lateral femoral cutaneous nerve, which traverses obliquely
“danger” (indicated by red color). from front to back in the upper lateral thigh, is easily pushed
When a direction of insertion is designated “safe,” a full out of the way when a trocar and sleeve is used for pin
pin can be used in place of a half-pin in such locations when insertion.
more stability and additional xation are needed on the In the middle of the thigh, between zones B and C, the
opposite side of the extremity. Bear in mind, however, that supercial femoral artery crosses the coronal plane of the
when a threaded pin is driven through soft tissue without a limb one bone diameter medial to the femur. The deep
drill sleeve, wrapping up of soft tissues can cause signicant femoral artery and veins lie adjacent to the posterior-medial
problems. Although drill sleeves are widely used in conjunc- corner of the femur in the lower part of zone B, but this has
tion with pin insertion on the near side of the limb, no such not been a clinical problem, perhaps because the vessels are
sleeves exist to protect soft tissues on the limb’s far side. To behind the coronal plane of the bone (Fig. 8.40).
overcome such concerns, special centrally threaded pins (with At times, surgeons insert pins into the femur in the anterior-
smooth shafts on both sides of the threads) were developed to-posterior direction, impaling the rectus femoris as they
in the 1970s. Unfortunately, they are rarely, if ever, used do so. Whereas the anterior-to-posterior direction is generally
nowadays, and may not be available except on special order. safe (because the sciatic nerve is more than one bone diameter
When external xators are applied in damage control away from the femur), transxing the rectus femoris eliminates
orthopaedics, full pins (through-and-through) are virtually knee exion. Although this may be desirable in damage
never employed; half-pins serve well in virtually all anatomic control orthopaedics, especially when the distal femur or
locations.94,96–98 upper tibia is shattered, there is risk that the central part of
the quadriceps muscle will adhere to the bone if the xator
DANGER REGIONS FOR PERCUTANEOUS PINS is left in place for too long. It often happens that a
INSERTED WITHOUT FLUOROSCOPY
As mentioned earlier, forward eld hospitals in combat situ-
ations often lack uoroscope capabilities, so military surgeons
were wondering about the safety of “blind” insertion into
lower extremities (i.e., half-pin insertion without the use of
uoroscopy). Topp and colleagues,107 working at the Brooke
Army Medical Center, used cadaveric lower extremities to
assess the accuracy and safety of xator application under
such trying circumstances. They concluded that if military
surgeons conned their pin insertion locations and directions
to certain safe corridors, the likelihood of signicant nerve
or vessel injuries caused by the pins were within acceptable
limits, considering the nature of the casualties being treated.
Moreover, they learned that surgeons with greater experience
with external xation were less likely to overpenetrate very Fig. 8.40 Half-pins can be safely inserted from front to back (taking
much past the far cortex during pin insertion.107 care not to overpenetrate past the bone) to most of the femur. However,
As a general principle, whether inserting external xation quadriceps impalement is undesirable. Coronal plane pins can safely
pins or wires with or without uoroscopy, certain nerve or be inserted in most regions of the thigh as shown in zone D here.
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cHaPter 8 — PrinciPleS and comPlicationS of external Skeletal fixation 251
well-thought-out sequence of therapeutic interventions may about depth on the opposite side of the bone. In most loca-
be interrupted because the patient is transported to a different tions, a 30-mm thread length that cannot overpenetrate is
facility under the care of different doctors. Alternatively, quite safe. Throughout the lower leg, the neurovascular
problems pop up during treatment that make it necessary structures at risk are generally a bone diameter away from
for the surgeon to leave the external xation device on the the far surface of the tibia. An even safer direction, except
limb for longer than originally anticipated. Weeks sometimes for one location, is to insert the pins in the coronal plane,
stretch into months. Patients lay around in extended-care something that can be accomplished from either the medial
facilities waiting for insurance issues or scheduling consid- or the lateral side of the bone (Fig. 8.41). Of course, inserting
erations, or some other delay in prompt conversion from pins on the lateral side of the bone in the coronal plane
external xation to internal xation, resulting in protracted means that the implants must cross the muscles of the anterior
time in the frame. compartment, thereby limiting ankle motion if this is desired.
The best way to prevent quadriceps binding to the front Inserting pins from the medial side, although perhaps a bit
of the femur is to apply pins, even those that are used more difcult because of interference with the opposite limb
temporarily, from the lateral side in the coronal plane or during the surgery, is remarkably safe. In fact, even if the
even aiming slightly anteriorly from slightly posteriorly (to pin passes through into the limb and sticks out from both
avoid impaling the deep femoral artery). sides, no neurovascular structures are likely to be injured,
Typically, applying the xator from the lateral side of the with one exception. As mentioned earlier, at the junction of
femur and extending the conguration to the tibia means the third and fourth quarters of the tibia (zones C and D),
that some kind of articulation and intercalary bar must be the anterior tibial artery and deep peroneal nerve rest directly
used to get from the outer side of the femur to the inner on the lateral surface of the tibia and thus could be injured
side of the tibia. This is because most tibial mountings for by a coronal pin (Fig. 8.42).
damage control orthopaedics occur from the medial side of These neurovascular structures traverse obliquely from
the bone where the osseous surface is the subcutaneous. posterior to anterior and cannot easily slide out of the way
when a pin passes nearby because of their tight attachment
TIBIA to the bone. Fortunately, most of the innervation of the deep
The entire anterior-medial subcutaneous surface of the tibia
seems ideal for external xation pin insertion, even without
the use of uoroscopy. Having said that, the natural tendency
is to insert the pin perpendicular to the at surface of the
tibia. This approach is generally safe if the surgeon is careful
Fig. 8.41 Half-pins or full pins can be inserted in the coronal plane
through most of the tibia except at the junction of the third and fourth
quarters (lower zone C and upper zone D) where the anterior tibial Fig. 8.42 As with the proximal tibia, full pins and half-pins can be
artery and deep peroneal nerve crosses the coronal plane of the tibia inserted in the coronal plane of the bone below the crossing point of
on the lateral surface of the bone. With control of depth, half-pins can the anterior tibial artery in deep peroneal nerve. Likewise, throughout
be inserted throughout the tibia perpendicular to the subcutaneous the tibia, half-pins can be inserted perpendicular to the medial sub-
surface. cutaneous surface.
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252 Section one — General PrinciPleS
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