External Fixation

What are External Fixators?

External fixators are hardware devices utilized to hold broken bones in place together while they heal. They are basically used to provide stability to bone and soft tissue after a severe fracture, restore limb length, correct bone misalignment, or safeguard soft tissue after a severe burn or injury.

In an external fixator insertion procedure, fixation devices such as screws or metal pins are placed into the bone on both sides of the fracture through tiny incisions into the muscle and skin. These screws and pins are connected to a series of clamps and bars known as the external frame outside the skin. The device can be adjusted externally to make sure the bones stay in a proper position during the healing process.

Indications for Placement of External Fixators

External fixators are most commonly employed for fractures of the shinbone (tibia and fibula) or the lower leg. Your physician may recommend external fixators for the following reasons:

• Severe fractures with damage to soft tissue
• Infected fractures
• Burn injuries
• Lengthen a bone
• Straighten a deformed bone
• Decrease pressure on a joint through joint distraction

External fixators are also commonly used in patients with lower healing ability and skin conditions, such as:

• Peripheral vascular disease
• Osteomyelitis (bone infection)
• Diabetes

Preparation for Placement of External Fixators

In general, preoperative preparation for placement of external fixators will involve the following steps:

• A thorough examination is performed by your doctor to check for any medical issues that need to be addressed prior to the procedure.
• Depending on your medical history, social history, and age, you may need to undergo tests such as blood work and imaging to screen for any abnormalities that could compromise the safety of the procedure.
• You will be asked if you have allergies to medications, anesthesia, or latex.
• You should inform your doctor of any medications or supplements that you are taking or any medical conditions you have such as diabetes or heart disease.
• You may need to refrain from medications such as blood thinners or anti-inflammatories for a week or two prior to the procedure.
• You should not consume any solids or liquids at least 8 hours prior to the procedure.
• You need to make arrangements for someone to drive you home after you are discharged from the hospital.
• A written consent will be obtained from you after the procedure has been explained in detail.

Procedure for Placement of External Fixators

External fixator placement is a minimally invasive procedure usually performed under general anesthesia and involves the following steps:

• You will be placed on the operating table in a specific position that gives the best access to the treatment area.
• Your surgeon cleans the treatment area thoroughly with an antiseptic solution.
• Small holes are made into the undamaged areas of bones around the fracture site using a drill.
• Using a fluoroscope (live x-ray), fixation devices such as pins or wires are inserted through the holes.
• Outside of the body, metal bars with ball-and-socket joints are joined with the pins to provide rigid support. This is called an external frame.
• The fracture can be set in proper anatomical position by adjusting the ball-and-socket joints in the device.
• After fixing the bars, regular cleaning where the pins have been placed should be performed to avoid infection at the surgery site.
• In most instances, the external fixator may be required to remain in place for many weeks or even months.

Postoperative Care and Recovery

In general, postoperative care instructions and recovery after placement of external fixators will involve the following steps:

• You will be transferred to the recovery area where your nurse will closely observe you for any allergic/anesthetic reactions and monitor your vital signs as you recover.
• You may notice some pain, swelling, and discomfort in the treatment area. Pain and anti-inflammatory medications are provided as needed.
• Antibiotics are also prescribed to address the risk of surgery-related infection.
• Keep the foot elevated at or above the level of your heart to help minimize swelling and discomfort for a specified period of time.
• Do not weight-bear on the operated leg. A walking boot or a non-weight-bearing cast is recommended for a few weeks to facilitate healing and support the foot.
• Assistive devices such as crutches and walkers are recommended to maintain balance and stability during the healing process.
• You may start rehabilitation or physical therapy as recommended by your surgeon after a month or two to improve range of motion. You should begin appropriate exercises to stretch and strengthen the muscles.
• Keep the surgical site clean and dry. Instructions on surgical site care and bathing will be provided.
• Refrain from strenuous activities and lifting heavy weights during the healing period. Most fractures of the lower leg take about 6 to 12 weeks to heal. A gradual increase in activities over a period of time is recommended.
• Return to full activities is recommended only when the bone has regained its normal strength and function and with your doctor’s approval.
• Periodic follow-up appointments will be scheduled to monitor your progress.

Risks and Complications

External fixator placement is a relatively safe procedure; however, as with any procedure, some risks and complications may occur, such as the following:

• Infection
• Bleeding
• Pain
• Swelling
• Damage to nerves and vessels
• Tendon or muscle damage
• Blood clots or deep vein thrombosis (DVT)
• Hardware irritation
• Adverse reactions to anesthesia
• Non-union of bones
• Hardware failure