1 General Aspects of External Fixation

1.1 Introduction hill (1898) and Albin Lambotte (1902). In the 1930s,
1940s, and 1950s other surgeons such as Roger Ander-
External fixation is a method for treating bone and joint son, Raul Hoffman, Robert and Jean Judet, and Jacques
injuries as well as for correcting skeletal deformities by Vidal continued the development of external fixation
attaching bones to an external device that stabilizes devices by improving the clamp, pin and bar tech-
the injured limb. Additionally, it allows manipulation nologies. In the former Soviet Union a 30-year period
of the limb segments to achieve restoration of length of intensive development occurred beginning in the
and alignment. 1950s thanks to the efforts of G.A. Ilizarov, K. Sivash,
A synonym for external fixation is “external os- O. Gudushauri, V. Kalnberz, M. Volkov, O. Oganesyan,
teosynthesis”. In contrast, internal osteosynthesis em- V. Demianov and S. Tkachenko. Various types of exter-
ploys devices implanted under the skin and muscle. nal fixation device are shown in Fig. 1.2.2.
External braces, cast splints and orthotic devices are Currently more than 1,000 external fixation devices
not considered external fixators.“Extrafocal osteosyn- are available in the orthopaedic marketplace. All of the
thesis”, “compression osteosynthesis” and “distraction external fixator devices have similar components and
osteosynthesis”are not synonymous with external fixa- can be divided into six frame types (Table 1.1). Types
tion. These concepts can be utilized with either internal I and II are single-plane. All the other frame types are
or external osteosynthesis.The concepts represented by multiplane. Only console transosseous elements (half-
these terms can be applied separately or in combina- pin constructs) can be fixed in monolateral (type I)
tion. For example, an external fixator can be used to and sectorial (type II) external supports. The mount-
apply compression and distraction at the same time. ing of frame types IV–VI is based on wires or pins, or
The term “transosseous osteosynthesis” is com- wires and pins in combination. All the above features
monly used in the Russian-speaking literature. are important for determining the biomechanical, clin-
ical and performance features of each type of external
fixation device. The constructions mentioned as exam-
1.2 Historical Background and ples of circular devices (type V) are the usual members
of this group. The majority of these devices are used in
Classification the clinic as hybrid constructions with sectorial, semi-
circular, and circular external supports.
The first external fixator was described by the Ameri-
External fixation techniques can be classified ac-
can J. Emsberry in 1831. In 1843, the French physician
cording to the following characteristics:
Malgaigne introduced a device for treating fractures of
the patella and olecranon (Fig. 1.2.1). This resembled a
clamp and was known as the Malgaigne fixator. • Insertion of transosseous elements to treat injury
The widespread practical use of external fixation to bone (fracture, nonunion) and soft tissues: in-
was popularized by the Belgian surgeons Clayton Park- trafocal, extrafocal.
• Biomechanical condition between bone fragments
(neutral, compression, distraction): combined (con-
secutive, alternating, synchronous).
• Zones of mechanical influence on bone fragments:
monolocal, bilocal, polylocal.
• Quantity and quality of zones of osteogenesis
(bone formation): monolocal, bilocal, polylocal.

These techniques are discussed in later chapters de-

Fig. 1.2.1. Malgaigne fixator voted specifically to all aspects of external fixation.
2 1 General Aspects of External Fixation

a b c

d e f

g h i
Fig. 1.2.2a–i. Fixation devices. a Lambotte, b Hoffman-Vidal, c Ilizarov, d Kalnberz, e Volkov-Oganesyan, f Demianov,
g Tkachenko, h Gudushauri, i Sivash
 1.2 Historical Background and Classification 3

j k l

m n o

p q r
Fig. 1.2.2j–r. j Lee, k Barabash, l Synthes, m Biomet, n OrthoFix, o Stryker, p Taylor spatial frame, q SUV-frame, r Poli Hex
4 1 General Aspects of External Fixation

Table 1.1. Principal types of external fixation device

Type Examples Features Schemes
I. Monolateral Lambotte, Hoffmann, AO/ASIF, 1. Built only on pins that capture both cor-
Wagner, Afaunov, Sushko tices but do not pass completely through
the bone (console transosseous elements,
known as half-pins)
2. All transosseous elements are installed in
one plane and on one side
3. The free ends of the pins are fixed to longitu-
dinal connecting bars
II. Bilateral Charnley, Hoffmann, Vidal-Adrey, 1. Built on through-and-through Steinmann
Roger-Anderson, Key, Hey-Groves, pins or K-wires
Gryaznukhin
2. All transosseous elements are inserted in
one plane and pass through both cortices
(true transfixation pins)
3. The transosseous elements are joined using
longitudinal connecting bars on each side,
thus forming the “frame”

III. Sectorial (arch) AO/ASIF, SKID 1. Pin placement is limited to sector ˛

(0<˛<180◦ )
2. Pin divergence of up to 180◦ does not in-
clude the placing of true transfixation tran-
sosseous elements (wires and Steinmann
pins)
3. Devices are attached to and built upon the
console transosseous elements (half-pins,
console wires)
IV. Semicircular Fischer, Hoffmann-Vidal, 1. External supports geometrically form sector
Gudushauri, Sivash, ˇ (180≤ ˇ<360◦ )
Volkov-Oganesyan
2. All types of transosseous elements can be
used (Steinmann rods, K-wires, S-screws,
half-pins)

V. Circular Ilizarov, Kalnberz, Demianov, 1. The external rings and connecting bars com-
Tkachenko, Lee, Kronner, pletely surround the limb at the level of the
Monticelli-Spinelli, Ettinger application
2. This frame geometry can be varied to form
many configurations such as a ring, oval,
square, polygon, etc.
3. All types of transosseous elements can be
used (Steinmann pins, half-pins, wires)

VI. Hybrid Biomet hybrid external fixator, This type of external fixation device can com-
(Combined) Sheffield hybrid external fixator, bine all the features of types I–V
OrthoFix hybrid external fixator,
Taylor spatial frame, SUV-frame,
Poli Hex
 1.3 Advantages and Disadvantages, Indications and Contraindications 5

When evaluating all currently available external fix- 2. The constant monitoring of the device, with the
ation devices, the apparatus of G.A. Ilizarov is the most possibilities of loosening and hardware failure. The
complete. Although the entire array of components ap- constant threat of pin/wire site inflammation and
pears very complex on initial examination, the device deep pin tract infection throughout the entire pe-
allows any of the types of device for transosseous os- riod of frame application and use.
teosynthesis described above to be assembled. Addi- 3. Risk of stiffness of transfixed joints (“transfixion
tionally, it allows the use of any method of osteosyn- pin-induced joint stiffness”).
thesis alone or in combination and the application of 4. The frequently large size of the external fixation
these methods simultaneously within the same limb. device, which can be aesthetically unpleasing for
Because of this versatility, we pay particular attention the patient and often requires the use of special
to this specific device. clothing to cover the device.
5. Patient compliance is perhaps the biggest disadvan-
tage to the use of these devices as a noncompliant
patient not performing the required adjustments or
1.3 Advantages and a third party performing ill-conceived adjustments
Disadvantages, Indications and make continued treatment problematic.
Contraindications External fixators can be used in a wide variety of areas
including:
Each method of osteosynthesis has its own distinct ad-
vantages and disadvantages.External fixation has many 1. Fractures of virtually all bones of the skeleton, in-
advantages for the treatment of orthopaedic conditions cluding the pelvis, humerus, forearm, clavicle, fe-
including: mur, tibia, and foot/ankle:
– Frames may be applied at any level: diaphyseal,
epi-/metaphyseal, intraarticular.
1. Minimal disruption of soft tissues within the re-
– Simple, comminuted, segmental fractures.
gion of trauma or fracture, with preservation of the
– Open or closed fractures.
blood supply. This is important as local vascularity
– Fractures with the potential for soft-tissue con-
is a major factor in regeneration for bone healing.
tamination and infection.
2. Provision of stable fixation outside the zone of in-
2. Malunions/nonunions:
jury.
– Delayed union and nonunion.
3. The opportunity for closed reduction and repo-
– Malunions, traumatic deformities, soft-tissue or
sitioning of bone fragments. This can be accom-
bony defects.
plished in all three planes simultaneously.
– Infected malunions/nonunions.
4. Facilitation of an earlier return to function of the
3. Orthopaedic pathology:
injured extremity.
– Congenital deformities, bony defects, segmental
5. The ability to manipulate the biomechanical rigid-
bone resections for pathological conditions.
ity of the fixation device as it relates to the fixation
– Infected orthopaedic pathology.
of bone fragments.
4. Joint pathology:
6. A variety of uses for the treatment of pathological
– Malformations.
and traumatic orthopaedic diseases. The versatility
– Contractures.
of the device provides practically unlimited poten-
– Dislocations.
tial.
– Dysplasia or degenerative disease.
7. The opportunity to make adjustments to the de-
vice based on the individual patient’s clinical and Currently, the basic indications for the use of external
radiographic progress. Adjustments can be carried fixators include:
out indefinitely for the treatment of various or-
1. Fractures and dislocations accompanying soft-
thopaedic conditions, including the reconstruction
tissue damage.
of bony defects.
2. Penetrating injuries to joints, including injuries re-
8. The unique opportunity to study in both the clinical
sulting from gunshot wounds.
and basic science settings issues of bone and soft-
3. The rapid stabilization of fractures in haemody-
tissue regeneration.
namically unstable patients, including patients with
The basic disadvantages of external fixation include: multiple fractures or multiple injuries.
4. Fractures with extensive damage, including com-
1. The relative complexity of using external fixation minution and periosteal stripping (C3 in the AO/
devices, especially those of types IV–VI. ASIF classification).
6 1 General Aspects of External Fixation

5. Situations when the use of internal osteosynthesis 1.4 Equipment

is contraindicated in a particular patient, includ-
ing the presence of acute or chronic focal infec- The standard complete set of Ilizarov apparatus for os-
tion. teosynthesis is shown in Fig. 1.4.1.
6. (Infected) malunions, nonunions, traumatic defor- The standard instrumentation of a basic Ilizarov set
mities, and soft-tissue or bony defects. for transosseous osteosynthesis includes all the avail-
7. (Infected) congenital deformities, bony defects, and able equipment (Figs. 1.4.2–1.4.12 and 1.8.2). The ap-
segmental bone resections for pathological condi- plication of an external fixator requires basic operating
tions. room equipment including a surgical drill, and a radio-
8. Aesthetic surgery involving limb length discrep- lucent orthopaedic table with an attached device for
ancy, malformations and malalignment. applying skeletal traction. Plastic or rubber protection
9. In joint pathology (malformations, contractures, stoppers in diameters of 10–15 mm for pins/wires and
dislocations, dysplasia or degenerative disease). 20–25 mm for half-pins are necessary for fixing of gauze
10. Reconstructive operations: “tibialization” of the dressings.
fibula, lengthening of a stump, correction of hand A device for division of an extremity into lev-
and foot deformities; arthrodesis (including length- els (Fig. 1.8.2) allows a limb segment or a level to
ening arthrodesis). which transosseous elements can be attached to be
11. External fixation is also particularly useful in quickly and precisely defined (see section 1.8). Addi-
patients requiring distraction osteogenesis with tional equipment for performing “combined strained
chronic ischemic vascular conditions, such as oblit- fixation” is also discussed in the same chapter.
erating endarteritis, diabetes, peripheral vascular
disease, etc.
12. Growing (via lengthening) of soft tissues: skin,mus- 1.5 General Terms for External
cles, tendons, vessels, nerves.
13. Ancillary uses, including for example, the elimina- Fixation Constructs
tion of a luxation before joint arthroplasty.
Application of external fixation uses transosseous ele-
ments:
Some basic contraindications to the use of external fix-
ation include:
• Transsegmental elements comprise transfixation
1. Unfamiliarity of the surgeon with the use and me- K-wires and Steinmann pins.
chanics of external fixation,particularly distraction • Console elements comprise S-screws, half-pins and
osteogenesis. console wires.
2. Impossibility of constant monitoring of the patient
during the fixation period. Exterior supports of the frame are called basic supports.
3. Inability to monitor a patient’s external fixation and Transosseous elements fixed to the basic supports are
fracture healing postoperatively because of social designated as basic transosseous elements.The supports
or compliance issues, or inability of the patient to located between basic supports are called reductionally
follow postoperative recommendations and advice fixing or intermediate supports. Reductionally fixing
because of other factors. These may include age- transosseous elements are fixed to the reductionally fix-
related issues, psychoemotional status, and alco- ing supports (Fig. 1.5.1a).
hol or narcotic abuse which may inhibit a patient’s If the arrangement of the apparatus includes only
judgement regarding care and management of an the basic support on one of the bone fragments, both
external fixator. the basic and reductionally fixing transosseous ele-
4. Gross haemodynamic instability, in which even ments are fixed to it.In this case the reductionally fixing
rapid application of spanning external fixation transosseous elements are connected to the base sup-
would compromise the patient’s prognosis. port with the help of posts (Fig. 1.5.1b).
5. Gross contamination of soft tissues, the placement The basic and reductionally fixing transosseous ele-
of external fixator pins or wires through which ments and supports to which they are fixed make a tran-
would put the patient at increased risk of infection. sosseous module fixing the bone fragment. The pres-
6. HIV-positive patients who would otherwise benefit ence of two bone fragments implies two transosseous
from nonoperative management of fractures. modules: a proximal transosseous module and a dis-
7. Situations when the use of external fixation has no tal transosseous module (Fig. 1.5.1a). The basic support
clear advantage over conservative treatment and/or with both basic and reductionally fixing transosseous
internal fixation. elements is also a transosseous module (Fig. 1.5.1b).
 1.5 General Terms for External Fixation Constructs 7

a b

c d

g
e

f h

Fig. 1.4.1a–k. The standard complete set for osteosynthesis utilizing Ilizarov’s method. a External supports of different stan-
dard sizes: rings, half rings, sector rings (two-thirds, three-quarter or five-eighths rings), arches. b Connecting plates of differ-
ent standard sizes, including straight plates, twisted plates, curved plates. c One- to four-hole male and female posts. d Long
and short connecting plates of different lengths; long connecting plates with treaded ends. e Different length connecting
rods of different lengths including partially threaded, fully threaded and telescopic rods. f Slotted threaded rods: traction
clips. g Smooth and stop wires of diameter 1.5, 1.8 and 2.0 mm. h Wire fixation frame (Russian only); wire-fixation bolts.
i Wire tensioners; standard and dynamometric. j Bolts, nuts, lock washers, slotted washers, serrated washers, conical washers,
conical and spherical washers; threaded sockets and bushes. k Regular flat-nosed and round-nosed pliers, standard 10-mm
spanners
8 1 General Aspects of External Fixation

a b
Fig. 1.4.2a,b. Lever wire tensioners: Voronkevich (a) and assembled from the standard Ilizarov set (b). These tensioners allow
wires in inaccessible locations to be tightened

Fig. 1.4.3a–d. For the application of a hybrid (half-pin and transfixion wire) external fixator, utilizing cortical and metaphy-
seal 4-, 5- and 6-mm half-pins (a), a special ‘T’ wrench, either standard (b) or assembled from the Ilizarov set (c), is utilized.
Attachment of half-pins to the frame is accomplished using multiple pin fixation clamps (d) or L-shaped clips (Fig. 1.11.7)
 1.5 General Terms for External Fixation Constructs 9

Fig. 1.4.4. Cannulated drill sleeve (1) and trocar (4) assemblies are utilized for the introduction of half-pins. These are designed
to protect the soft tissue from damage and allow the drill to be directed at the desired angle. The drill sleeve has an attached
handle and has an inner diameter of 6.5 mm (1). The attached clamp (2) has a special guide for introduction of a calibrated
wire (3) which indicates the angle of pin insertion

Fig. 1.4.5. Surgical drills. The cortex at the proposed pin site is carefully predrilled avoiding damage to the soft tissue prior
to the introduction of a half-pin. A stop on the drill bits control the depth of drill penetration. Drills of different diameter are
required and should include diameters of: 2.7 mm, 3.8 mm 4.5 mm and 4.8 mm

Fig. 1.4.6. Traction clips at the site of fixing of a wire have a cube shape for easy capture by a spanner