External Fixation in Lower limb Fractures

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External Fixation in Lower limb Fractures
External Fixation in Lower Limb Fractures
Manuel Cassiano Neves Childrens Hospital Dona
Estefânia - Lisbon
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External Fixation in Lower limb Fractures
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External Fixation in Lower limb Fractures
Summary

• Background
• Review of the Literature
• Indications
• Pros and Cons
• Conclusion

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External Fixation in Lower limb Fractures
The concept of external skeletal fixation was
introduced by Malgaigne in 1840, with a spike
driven into the human tibia that was held by a
strap encircling the limb.
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External Fixation in Lower limb Fractures
Lambotte's first external fixator 1902
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External Fixation in Lower limb Fractures
The Hoffmann external fixator - 1936
Hoffman II - 2007
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External Fixation in Lower limb Fractures
What happen between 1936 - 1980 ?

• Pin tract infection
• High risk of osteomyelitis
• Mal-Union
• Risk of Refracture

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External Fixation in Lower limb Fractures
Medline - External Fixation in Children for the
last 20 years

• 45 articles
• 2/3 between 1990 1999

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External Fixation in Lower limb Fractures
Medline - External Fixation in Children
Complex femur fractures in children treatment
with external fixation . D Kirschenbaum, MC
Albert, WW Robertson, RS Davidson. J Ped Orthop
10(5)588-91, 1990
Treatment of femoral shaft fractures in children
by external fixation. C Krettek, N Haas, J
Walker, H Tscherne. Injury 22()263-66, 1991
External fixation of femur fractures in children.
J Aronson, EA Tursky. J Ped Orthop 12(2)157-63,
1992
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External Fixation in Lower limb Fractures
Pros

• Easy to use
• Minimally Invasive
• Early recovery
• No need for second operation
• Lower costs in comparison with Non-
• Operative treatment

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External Fixation in Lower limb Fractures
Pros

• Easy to use
• Minimally Invasive
• Early recovery
• No need for second operation
• Lower costs in comparison with Non-
• Operative treatment
• Polytrauma child

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External Fixation in Lower limb Fractures
Cons

• Pin track infection

Outcomes of external fixation of pediatric
femoral shaft fractures. T Miner, KL Carroll. J
Pediatr Orthop 20(3)405-10, 2000

72,7 Infection
Rates of refracture associated with external
fixation in pediatric femur fractures. KD
Carmichael, J Bynum, J Goucher. Am J Orthop
34(9)439-44, 2005
33,1 Infection
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External Fixation in Lower limb Fractures
Cons

• Mal Union

Rates of refracture assocciated with external
fixation in pediatric femur fractures. KD
Carmichael, J Bynum, J Goucher. Am J Orthop
34(9)439-44, 2005

9,1 Mal-Union
Treatment of open femur fractures in children
comparison between external fixator and
intramedullary nailing . LE Ramseier, AR Bhaskar,
WG Cole, AW Howard. J Pediatr Orthop
27(7)748-50, 2007 12,2 Mal-Union
Radiological outcome after external fixation of
97 femoral shaft fractures in children. H Hedin,
K Hjorth, S Larsson, S Nilsson. Injury
34(4)287-92, 2003


15,1 Mal-Union at union but full
recovery at maturity
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External Fixation in Lower limb Fractures
Cons

• Longer time to heal

Open femur fractures in children treatment,
complications and results . CM Hutchins, PD
Sponseller, P Sturm, R Mosquero. J Pediatr
Orthop 20(2)183-8, 2000
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External Fixation in Lower limb Fractures
Cons

• High refracture rate (1,4 - 23)

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External Fixation in Lower limb Fractures
Cons

• High refracture rate

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External Fixation in Lower limb Fractures
Cons

• Pin track infection
• Mal Union
• Longer time to heal
• High refracture rate

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External Fixation in Lower limb Fractures
Is External Fixation still acceptable in 2009 for
the treatment of the lower limb diaphysial
fractures ?
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External Fixation in Lower limb Fractures
Children operated 2005 - 2008 Femur or Tibia
83 Children External Fixation ?
8 Children - 9,6
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External Fixation in Lower limb Fractures
Our Protocol

• Monolateral Ext. Fixator
• Minimum 8 corticals
• Schanz screws 4 - 5mm / 6.5mm
• Anatomical reduction

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External Fixation in Lower limb Fractures
Indications for External Fixation
5 y. old Girl Fall from hight Rt. Open
III b femur
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External Fixation in Lower limb Fractures
Indications for External Fixation
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External Fixation in Lower limb Fractures
Indications for External Fixation
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External Fixation in Lower limb Fractures
Indications for External Fixation
4 weeks
8 weeks
12 weeks
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External Fixation in Lower limb Fractures
Indications for External Fixation
11 y. old Boy Hit by a car Lt. distal
tibia Soft tissue compl.
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External Fixation in Lower limb Fractures
Indications for External Fixation
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External Fixation in Lower limb Fractures
Indications for External Fixation
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External Fixation in Lower limb Fractures
Indications for External Fixation
12 weeks
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External Fixation in Lower limb Fractures
7 y. old Girl Fall from the bike 15 d
pre-admission Operated at the time of
injury elsew. 2 cm shortening valgus
deformity 18º External rotation 30º
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External Fixation in Lower limb Fractures
2nd operation
2 weeks post accident
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External Fixation in Lower limb Fractures
6 weeks post-op.
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External Fixation in Lower limb Fractures
4 mo. post-op.
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External Fixation in Lower limb Fractures
16 mo. post-op.
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External Fixation in Lower limb Fractures
Indications for External Fixation
6 y. old Boy Hit by a car Bilateral
femur Lt. tibia
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External Fixation in Lower limb Fractures
Indications for External Fixation
6 w. Post-Op
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External Fixation in Lower limb Fractures
Our Results

• Indicated in 10 of our Children - 08/83
• Open fractures
  5
• Fractures assoc. Soft-Tissue Inj. 2
• Secondary Treatment 1

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External Fixation in Lower limb Fractures
Our Complications

• Severe infection
  1
• Pin-track infection
  68
• Late Union
  2
• Mal-Union
  0
• Leg length discrepancy gt 10mm 0
• Refracture rate
  0

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External Fixation in Lower limb Fractures
In Conclusion
Is External Fixation still acceptable in 2009 for
the treatment of the lower limb diaphysial
fractures ? YES
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External Fixation in Lower limb Fractures
Indications for External Fixation

• Open fractures
• s in assoc. with Soft Tissue Injuries
• Multiple fractures
• Polytrauma
• s associated with Head Trauma
• Mal-Alignment or unstable s

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