Advertisement

Diaphyseal Fractures

  • Dolfi HerscoviciJr.
  • Julia M. Scaduto
Chapter
  • 85 Downloads

Abstract

Temporary external fixation for the management of diaphyseal and intra-articular fractures is an extremely valuable tool for the care of trauma patients. Use of a simple uniplanar fixator will allow for quick application and greater access to the surrounding soft tissues and wounds. It is important to have a good understanding of the cross-sectional anatomy of the limb, to consider the three anatomic corridors (safe, hazardous, and unsafe) that can be used for pin placement, and to use good techniques for pin insertion. If more stability is needed, it can be increased with the addition of a second (intercalary) bar or by adding a posterior splint to the extremity. Lastly, there is insufficient evidence to promote any recommendations regarding the optimal frequency for pin site care or any specific recommendations addressing cleansing strategies of the pin site in order to reduce the risk of infection.

Keywords

External fixation Provisional fixation Spanning frames Damage control Uniplanar fixator Temporary fixation Diaphyseal and intra-articular fractures 

References

  1. 1.
    Malgaigne JF. Considérations cliniques sur les fractures de la rotule et leur traitment par les griffes. J des Connnaissances Med Pratiques. 1853;16:9.Google Scholar
  2. 2.
    Johnson HF, Stovall SL. External fixation of fractures. J Bone Joint Surg Am. 1950;32A(2):466–7.PubMedGoogle Scholar
  3. 3.
    Brooker A, Edwards C. External fixation: the current state of the art. Baltimore: Williams and Wilkins; 1979.Google Scholar
  4. 4.
    Mears DC. External skeletal fixation. Baltimore: Williams and Wilkins; 1981.Google Scholar
  5. 5.
    Behrens F, Jones RE 3rd, Fischer DA, Mears DC. External skeletal fixation. Instr Course Lect. 1981;30:112–82.PubMedGoogle Scholar
  6. 6.
    Behrens F. A primer of fixator devices and configurations. Clin Orthop Relat Res. 1989;(241):5–14.Google Scholar
  7. 7.
    Behrens F. General theory and principles of external fixation. Clin Orthop Relat Res. 1989;(241):15–23.Google Scholar
  8. 8.
    Behrens F, Johnson W. Unilateral external fixation. Methods to increase and reduce frame stiffness. Clin Orthop Relat Res. 1989;(241):48–56.Google Scholar
  9. 9.
    Behrens F, Johnson WD, Koch TW, Kovacevic N. Bending stiffness of unilateral and bilateral fixator frames. Clin Orthop Relat Res. 1983;(178):103–10.Google Scholar
  10. 10.
    Holt J, Hertzberg B, Weinhold P, Storm W, Schoenfisch M, Dahners L. Decreasing bacterial colonization of external fixation pins through nitric oxide release coatings. J Orthop Trauma. 2011;25(7):432–7.CrossRefGoogle Scholar
  11. 11.
    Jennison T, McNally M, Pandit H. Prevention of infection in external fixator pin sites. Acta Biomater. 2014;10(2):595–603.CrossRefGoogle Scholar
  12. 12.
    Gil D, Shuvaev S, Frank-Kamenetskii A, Reukov V, Gross C, Vertegel A. Novel antibacterial coating on orthopedic wires to eliminate pin tract infections. Antimicrob Agents Chemother. 2017;61(7):e00442–17.  https://doi.org/10.1128/AAC.00442-17.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Slate AJ, Wickens DJ, El Mohtadi M, Dempsey-Hibbet N, West G, Banks CE, Whitehead KA. Antimicrobial activity of Ti-ZrN/Ag coatings for use in biomaterial applications. Sci Rep. 2018;8:1497.  https://doi.org/10.1038/s41598-018-20013-z. Author correction: Sci Rep. 2018;8(1):6251.  https://doi.org/10.1038/s41598-018-24174-9.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Toksvig-Larsen S, Aspenberg P. Bisphosphonate-coated external fixator pins appear similar to hydroxyapatite-coated pins in the tibial metaphysis and to uncoated pins in the shaft. Acta Orthop. 2013;84(3):314–8.CrossRefGoogle Scholar
  15. 15.
    Eriksson A, Albrektsson T, Grane B, McQueen D. Thermal injury to bone: a vital microscopic description of heat effects. Int J Oral Surg. 1982;11(2):115–21.CrossRefGoogle Scholar
  16. 16.
    Moroni A, Vannini F, Mosca M, Giannini S. Techniques to avoid pin loosening and infection in external fixation. J Orthop Trauma. 2002;16(3):189–95.CrossRefGoogle Scholar
  17. 17.
    Aro HT, Hein TJ, Chao EY. Mechanical performance of pin clamps in external fixators. Clin Orthop Relat Res. 1989;(248):246–53.Google Scholar
  18. 18.
    Kowalski M, Schemitsch EH, Harrington RM, Chapman JR, Swiontkowski MF. Comparative biomechanical evaluation of different external fixation sidebars: stainless- steel tubes versus carbon fiber rods. J Orthop Trauma. 1996;10(7):470–5.CrossRefGoogle Scholar
  19. 19.
    Faist E, Baue AE, Dittmer H, Heberer G. Multiple organ failure in polytrauma patients. J Trauma. 1983;23(9):775–87.CrossRefGoogle Scholar
  20. 20.
    Pape HC, Rixen D, Morley J, Husebye EE, Mueller M, Dumont C, et al.; EPOFF Study Group. Impact of the method of initial stabilization for femoral shaft fractures in patients with multiple injuries at risk for complications (borderline patients). Ann Surg. 2007;246(3):491–9; discussion 499–501.Google Scholar
  21. 21.
    Morshed S, Miclau T III, Benbom O, Cohen M, Knudson MM, Colford JM Jr. Delayed internal fixation of femoral shaft fracture reduces mortality among patients with multisystem trauma. J Bone Joint Surg Am. 2009;91(1):3–13.CrossRefGoogle Scholar
  22. 22.
    Scalea TM, Boswell SA, Scott JD, Mitchell KA, Kramer ME, Pollak AN. External fixation as a bridge to intramedullary nailing for patients with multiple injuries and with femur fractures: damage control orthopedics. J Trauma. 2000;48(4):613–21; discussion 621–3.CrossRefGoogle Scholar
  23. 23.
    Rotondo MF, Schwab CW, McGonigal MD, Phillips GR 3rd, Fruchterman TM, Kauder DR, et al. ‘Damage control’: an approach for improved survival in exsanguinating penetrating abdominal injury. J Trauma. 1993;35(3):375–82.CrossRefGoogle Scholar
  24. 24.
    Tscherne H, Regel G, Pape HC, Pohlemann T, Krettek C. Internal fixation of multiple fractures in patients with polytrauma. Clin Orthop Relat Res. 1998;(347):62–78.CrossRefGoogle Scholar
  25. 25.
    Tuttle MS, Smith WR, Williams AE, Agudelo JF, Hartshorn CJ, Moore EE, Morgan SJ. Safety and efficacy of damage control external fixation versus definitive stabilization for femoral shaft fractures in the multiple-injured patient. J Trauma. 2009;67(3):602–5.CrossRefGoogle Scholar
  26. 26.
    Haidukewych GJ. Temporary external fixation for the management of complex intra- and periarticular fractures of the lower extremity. J Orthop Trauma. 2002;16(9):678–85.CrossRefGoogle Scholar
  27. 27.
    Sirkin M, Sanders R, DiPasquale T, Herscovici D Jr. A staged protocol for soft tissue management in the treatment of complex pilon fractures. J Orthop Trauma. 1999;13(2):78–84.CrossRefGoogle Scholar
  28. 28.
    Egol KA, Tejwani NC, Capla EL, Wolinsky PL, Koval KJ. Staged management of high-energy proximal tibia fractures (OTA Types 41). J Orthop Trauma. 2005;19(7):448–55.CrossRefGoogle Scholar
  29. 29.
    Min W, Ding BC, Tejwani NC. Staged versus acute definitive management of open distal humeral fractures. J Trauma. 2011;71(4):944–7.CrossRefGoogle Scholar
  30. 30.
    Wang W, Yao N, Song X, Yan Y, Wang C. External spinal skeletal fixation combination with percutaneous injury vertebra bone grafting in the treatment of thoracolumbar fractures. Spine (Phila Pa 1976). 2011;36(9):E606–11.CrossRefGoogle Scholar
  31. 31.
    Henley MB, Peter RE, Benirschke SK, Ashbaugh D. External fixation of the sternum for thoracic trauma. J Orthop Trauma. 1991;5(4):493–7.CrossRefGoogle Scholar
  32. 32.
    Ziran BH, Smith WR, Anglen JO, Tornetta P 3rd. External fixation: how to make it work. J Bone Joint Surg Am. 2007;89(7):1620–32.CrossRefGoogle Scholar
  33. 33.
    Seitz WH Jr, Fromison AI, Brooks DB, Postak P, Polando G, Greenwald AS. External fixator pin insertion techniques; biomechanical analysis and clinical relevance. J Hand Surg Am. 1991;16(3):560–3.CrossRefGoogle Scholar
  34. 34.
    Lowery K, Dearden P, Sherman K, Mahadevan V, Sharma H. Cadaveric analysis of capsular attachments of the distal femur related to pin and wire placement. Injury. 2015;46(6):970–4.CrossRefGoogle Scholar
  35. 35.
    DeCoster TA, Crawford MK, Kraut MA. Safe extracapsular placement of proximal tibial transfixation pins. J Orthop Trauma. 2004;18(Suppl 8):43–7.CrossRefGoogle Scholar
  36. 36.
    Nowotarski PJ, Turen CH, Brumback RJ, Scarboro JM. Conversion of external fixation to intramedullary nailing for fractures of the shaft of the femur in multiply injured patients. J Bone Joint Surg Am. 2000;82(6):781–8.CrossRefGoogle Scholar
  37. 37.
    Winquist R, Hansen S. Comminuted fractures of the femoral shaft treated by intramedullary nailing. Orthop Clin N Am. 1980;11(3):633–47.Google Scholar
  38. 38.
    Stahel PF, Mauffrey C, Smith WR, McKean J, Hao J, Burlew CC, Moore EE. External fixation for acute pelvic ring injuries: decision making and technical options. J Trauma Acute Care Surg. 2013;75(5):882–7.CrossRefGoogle Scholar
  39. 39.
    Casey D, McConnell T, Parekh S, Tornetta P 3rd. Percutaneous pin placement in the medial calcaneus: is anywhere safe? J Orthop Trauma. 2004;18(8 Suppl):S39–42.CrossRefGoogle Scholar
  40. 40.
    Kazmers NH, Fragomen AT, Rozbruch SR. Prevention of pin site infection in external fixation: a review of the literature. Strategies Trauma Limb Reconstr. 2016;11(2):75–85.CrossRefGoogle Scholar
  41. 41.
    Parameswaran AD, Roberts CS, Seligson D, Voor M. Pin tract infection with contemporary external fixation: how much of a problem? J Orthop Trauma. 2003;17(7):503–7.CrossRefGoogle Scholar
  42. 42.
    Ceroni D, Grumetz C, Desvachez O, Pusateri S, Dunand P, Samara E. From prevention of pin-tract infection to treatment of osteomyelitis during paediatric external fixation. J Child Orthop. 2016;10:605–12.CrossRefGoogle Scholar
  43. 43.
    Dahl MT, Gulli B, Berg T. Complications of limb lengthening. A learning curve. Clin Orthop Relat Res. 1994;(301):10–8.Google Scholar
  44. 44.
    Checketts RG, MacEachem AG, Otterbum M. Pin tract infection and the principles of pin site care. In: DeBastiani G, Apley AG, Goldberg AA, editors. Orthofix external fixation in trauma and orthopaedics. London: Springer-Verlag London Ltd; 2000. p. 97–103.CrossRefGoogle Scholar
  45. 45.
    Lethaby A, Temple J, Santy J. Pin site care for preventing infections associated with external bone fixators and pins. Cochrane Database Syst Rev. 2008;(4):CD004551.  https://doi.org/10.1002/14651858.CD004551.pub2.
  46. 46.
    Lethaby A, Temple J, Santy-Tomlinson J. Pin site care for preventing infections associated with external bone fixators and pins. Cochrane Database Syst Rev. 2013;(12):CD004551.  https://doi.org/10.1002/14651858.CD004551.pub3.

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Dolfi HerscoviciJr.
    • 1
  • Julia M. Scaduto
    • 1
  1. 1.Center for Bone and Joint DiseaseHudsonUSA

Personalised recommendations