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Modular external fixation

Basic technique

2/6 – Pin insertion

1. Principles
Modular external fixator

The modular external fixator is optimal for

temporary use. It is rapidly applied without need for
intraoperative x-rays and can be adjusted later.

The frame of a modular external fixator consists of

two partial frames (a, b), one on each main fracture
fragment. Each partial frame consists of two pins
in a bone fragment, connected with a rod. The two
frames are joined with a rod-to-rod
construction/connecting rod (c).

This construct allows manipulation and reduction

of the fracture after pin placement and guarantees
sufficient stiffness of the frame. It also allows pins
to be inserted through safe zones, avoiding
traumatized soft tissues.

Optimal frame construction

For the construction of the frame consider the

following points:

Pins are placed near the fracture site, but not

too close to it, and so they avoid traumatized
soft tissue (a)
Pins are placed so that they are widely
separated in each main fracture fragment (b)
Rods are connected to the pins with rod-to-
pin clamps (c)
The rod-to-pin clamps are fully tightened so
that each main fragment has its own partial
frame

Pins can be ‘preloaded’ to improve their purchase

in bone and to reduce the tendency to loosen over
time. This can be achieved by either (1) the design
of the pin, or (2) by how the pin(s) is/are implanted.

Achieving preload through pin design: a tapered

pin in which the largest (proximal) diameter is
slightly greater than the drill hole through which it
is introduced will induce radial preload in the near
cortex of the bone into which it is implanted.
Inducing too much radial preload (caused by
introducing a screw that is too large for the
predrilled cortical bone) may cause (1) local bone
microfractures or (2) bone ischaemia. Both may
lead to necrosis and early loosening so this should
be avoided.

Achieving preload through optimizing pin

implantation: reduction in the risk of loosening of
standard pins after implantation may be achieved
by tensioning adjacent pins towards or away from
each other. The load produced in the pin by the
resistance of the pin to bending produces an
asymmetrical load in the near cortical pin hole. If
adjacent pin holes experience opposing loads
then each pin neutralizes the tendency of the
adjacent pin to loosen.

Further information on this topic can be found

here:
Hyldahl C, Pearson S, Tepic S, et al. Induction and
prevention of pin loosening in external fixation:
an in vivo study on sheep tibiae. J Orthop Trauma.
1991;5(4):485-92.

The two partial frames are interconnected using a

connecting rod.

The clamps are first provisionally tightened with a

T-handle and then fully tightened using a wrench.

The stiffness of the frame may be increased by the

following options:

Using thicker pins

Positioning the rod closer to the bone
Adding a second connecting rod
(neutralization rod) (e) between the partial
frames
Placing more pins in each segment

Interactive 3D animation

These 3D models show the biomechanical

behavior of the construct. Increasing the distance
from the rod to the bone decreases the stiffness of
the frame of the external fixation system.
Therefore, the strain at the rod and the pin
(especially the outer pin) is increased.

Compressive stress is shown in red and tensile

stress is shown in blue in this animation.

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Interactive 3D animation

These 3D models show that by adding a third pin,

the strain concentration at each pin is slightly
reduced. The whole construct provides increased
stiffness, especially in torsion.

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Equipment needed

For the construction of the frame the following

components may be used (shown for the large
external fixator):

1. Threaded pins (Schanz type pins, standard or

self-drilling/self-tapping with radial preload; 5
or 6 mm)
2. Carbon fiber rods or metal tubes (diameter of
11 mm)
3. Rod-to-pin clamps (titanium, MRI safe)
4. Combination clamps (rod-to-rod or rod-to-
pin, self-holding, titanium, MRI safe)
5. Rod-to-pin clamps (old type, still in use)
6. Rod-to-rod clamps (old type, still in use)

Depending on the anatomic region, the large,

medium, small, or mini external fixation system will
be more appropriate. The pins, rods and clamps
are similar in all systems, but vary in dimensions.
For the application of special frames, further
components may be needed.

2. Pin insertion
Pin placement

Two pins should be inserted in the safe zones in

each of the proximal and distal fragments.

The risk of tendon penetration or injuries to nerves,

vessels, and muscles is determined by the
anatomy of each region. Pins should not be placed
where they will enter a joint cavity.

When possible, the use of an image intensifier is

recommended to facilitate optimal and safe pin
placement.

In temporary external fixation, the pins should be

placed so they do not interfere with planned later
definitive fixation.

Skin incision

The position of each skin incision is determined by

the pin position. As the fracture is reduced, the pin
may move in relation to the skin, and the incision
may then need to be extended in order to release
any tension in the skin. If possible, this should be
anticipated and the initial skin incision adjusted
accordingly.

Predrilling

Unless self-drilling pins are to be used it is

essential to predrill both cortices prior to the
insertion of threaded pins.

Place a drill sleeve with trocar through the

prepared soft-tissue channel to prevent damage to
soft tissues and confirm correct positioning. The
use of an image intensifier may be beneficial to
determine correct pin trajectories.

Drilling through cortical bone should be performed

under cooling to prevent heat formation followed
by bone necrosis.

Pin insertion (conventional threaded pins)

Insert conventional pins by hand using the

corresponding drill sleeve.

Ensure that both cortices are engaged; feeling the

pin thread itself into the opposite cortex confirms
correct insertion depth.

After the insertion of all pins, image intensification

control in two planes is recommended.

Conventional threaded pins should be bicortical so

that the thread of the pin is fully threaded in the
predrilled hole of the far cortex. The pins must not
protrude too far since this would endanger the soft
tissues.

Pin insertion (self-drilling Schanz screws)

Insert each pin through the drill sleeve. A power

tool is used to insert the screw through the near
cortex. Once the screw reaches the far cortex,
which can be felt easily, turn the pin manually for
another one or two rotations to anchor the tip of
the screw in the inner side of the far cortex.

Self-drilling and self-tapping pins must not

perforate the far cortex (the protruding sharp tip
can cause soft-tissue injury if it projects beyond
the cortex).

3. Frame construction
Frame assembly

Connect the two pins in each main fragment to a

rod using rod-to-pin clamps.

The rod should lie close to the bone and the skin,
but not so close as to risk pressure on the skin if
the limb subsequently swells. There should be
enough room between the rod and skin to allow
cleaning.

Fully tighten the rod-to-pin clamps to complete the

two partial frames.

Connect the two partial frames with a rod using

rod-to-rod clamps applied loosely enough to allow
reduction of the fracture.

Pitfall: conflicting rods

The ends of the two rods should not be placed

too close to each other as this could interfere
with reduction.

4. Reduction and fixation

Reduction

Using the partial frames as handles, manually

reduce the fracture to obtain appropriate length,
alignment, and rotation.

Check the provisional reduction in AP and lateral

image intensifier views.

Note: As a planned temporary external fixator

may turn out to be the definitive fixation, the
fracture should always be brought out to length
and reduced as accurately as is practical.

Pearl: When strong force is required to achieve

reduction, it may be helpful to temporarily add
rods to each partial frame to lengthen the lever
arm. These rods may be attached in whatever
orientation is most convenient. It is then easier
to apply the forces necessary for reduction.
This also helps to keep the surgeon’s hands
out of the image intensifier beam.

Fixation

When satisfactory reduction has been obtained,

tighten the rod-to-rod clamps to finalize the frame
construction. Reconfirm reduction using image
intensification.

If additional stability is needed to secure the

reduction, attach an additional rod (neutralization
rod) to the two partial frames. This may be
attached at each end to either a rod or a pin.

If needed, a curved rod or two connected rods may

be used.

Interactive 3D animation

The lower 3D model shows an additional rod

(neutralization rod) applied to a modular external
fixation frame. This increases the stiffness and the
stability of the construct. It adds rotational stability
in particular and increases the bending strength,
thus significantly reducing strains at the
connecting rod.
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Periarticular injuries

When the fracture lies close to a joint it may be

more practical to stabilize small periarticular
fragments with a joint-spanning frame.

This should generally be converted to a form of

fixation which allows the joint to move as soon as
is practical, otherwise there is a risk of long-term
stiffness.

Associated fractures

In a limb with fractures at more than one site, for

example ipsilateral femoral and tibial fractures,
where both fractures are treated with an external
fixator, it may be helpful to join the two frames.

Inspection and treatment of skin incisions

After the operation, stab incisions should be left

open and treated locally with antiseptic dressings.
Closing stab incisions prevents wound drainage,
which increases the risk of pin track infection.

If there is tension on one side, the incision should

be extended. If significant extension is required
and the total incision becomes unnecessarily long
the redundant portion of the incision may be
closed.

5. Subsequent management
after external fixation as
temporary fixation

If external fixation was used because the patient

was not fit to undergo definitive internal fixation,
once the general condition has improved,
definitive fixation may be considered.

Soft tissue healed

If the soft-tissue injuries have healed satisfactorily

without pin track infection, the external fixation can
safely be removed and replaced by internal fixation
if the pin sites are clean.

Soft-tissue problems persist

If there is pin track infection, changing to a

definitive internal fixation could lead to infection.

If the soft-tissue problems persist and/or the

external fixator has been left on for two weeks or
longer, or there are pin-track infections, the
following steps should be taken:

Remove the external fixator

Debride the pin sites in the operating theater,
using curettage and irrigation, taking
specimens for microbiological study
Temporarily stabilize in a splint or cast or
place a new external fixator at new pin sites
Let the pin tracks heal
Proceed with internal fixation, covering with
antibiotics, as necessary, and as determined
by any positive microbiological cultures

Pitfall: intramedullary infection

If there is a pin-track infection, using an

intramedullary nail (especially with reaming
technique) could lead to intramedullary
infection.
In this case plate osteosynthesis may be
preferable.

6. External fixation as definitive

fixation
Indications

In the event that soft-tissue healing is not

satisfactory after four to six weeks, and there is no
pin-track infection, the external fixator can be left
on until the fracture has healed.

In non-compliant patients the external fixator is

often indicated as the first and final treatment.

In children, fracture healing is often complete in six

to eight weeks. If external fixation is initially
chosen, it should remain until the fracture has
healed.

Adjusting the fixator

If a temporary fixator was initially rapidly applied

when the patient was severely injured, it may be
necessary to adjust the fixator to obtain an
appropriate reduction and provide additional
stability once the decision has been made to
continue external fixation as the definitive
treatment. In some cases, a new construct may be
better able to maintain satisfactory reduction until
the fracture has healed.

Optimal stiffness

A small amount of movement between the fracture

fragments will stimulate callus formation. In highly
fragmented fractures, movement is spread over
the entire fracture area, but in simple, two-part
fractures all movement occurs at only one fracture
site.

Inadequate stability will delay fracture healing.

However, beware of too much stiffness or rigidity,
as this may also delay healing, especially in open
fractures.

Pitfall: pin loosening or pin-track infection

In case of pin loosening or pin-track infection,

the following steps need to be taken:
• Remove all involved pins and place new pins
in a healthy location
• Debride the pin sites in the operating theater,
using curettage and irrigation
• Take specimens for a microbiological study
to guide appropriate antibiotic treatment
complementing the surgical debridement

Authors of basic technique

Special Author
Dankward Höntzsch
Executive Editor
Steve Krikler

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AO Surgery Reference

Hand - Middle
phalanges revision
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