Terminology

• Amputation: Intentional surgical removal of a limb or body part.

Aim

• Remove diseased or non-viable tissue (e.g., gangrene, infection, malignancy).
• Relieve pain.
• Construct a stump suitable for prosthetic fitting and functional use.

Amputation is considered when the limb cannot be salvaged or its salvage would result in poor function, high complication risk, or excessive resource use.

Situations like these include:

• Vascular compromise - Irreversible ischemia >6 hours, or limb not perfusing despite resuscitation.
• Severe soft tissue loss or contamination - Extensive loss of muscle, skin, or neurovascular structures (especially posterior compartment muscles) limits reconstructive options. 
• Bone loss - Salvage is time-consuming, requires a motivated and compliant patient, and can risk financial or social burden in low-resource settings. 
• Multitrauma / shock - Life-threatening injuries may necessitate amputation to prioritize patient survival. Patients with poor response to resuscitation may require early amputation to save life. 
• Neurological injury - Irreversible nerve damage that compromises limb function. Absence of plantar sensation alone is not an indication for primary amputation.
• Functional outcome - When limb salvage may result in chronic pain, limited mobility, or repeated interventions. 
• Patient and social factors - Age, comorbidities, occupation, limb dominance, cultural context, and the availability of prosthetics should guide decision-making. 
• Lifestyle factors - Smoking significantly increases the risk of non-union, osteomyelitis, delayed wound healing, surgical site infections, and soft tissue reconstruction failure¹.

In every case, amputation should be viewed as a deliberate reconstructive decision, not a surgical failure. It aims to restore the patient’s independence and functional mobility wherever possible. 

Mangled Extremity Severity Score (MESS) 

The MESS² is a validated tool to help guide decision-making for limb salvage versus amputation. However, the final decision is clinical (including psychosocial factors).

MESS ≤6: Limb salvage is generally feasible.
MESS ≥7: Amputation is often the outcome

* Points are doubled if ischemia duration >6 hours. 

Timing of amputation

Timing depends on patient condition: emergency to save life, urgent to prevent deterioration, elective to optimize function.

1 Emergency

• When - Within hours
• Indications - Severe bleeding, acute ischemia, or severe infection
• Goal - Save the patient’s life

2 Urgent

• When - Within 24–72 hours
• Indications - Failed revascularization, progressive infection, wet gangrene
• Goal - Prevent systemic deterioration

3 Elective (planned)

• When - Days to weeks after injury
• Indications - Chronic limb ischemia, non-healing ulcers, malignancy, limb deformity
• Goal - Maximize function and plan rehabilitation

Key Point

Amputation decisions should always be individualized, taking into account the patient’s clinical status, functional potential, and psychosocial context. Multidisciplinary input: including surgical, rehabilitation, and patient/family perspectives, is essential to achieve the best functional and quality-of-life outcomes.

Fasciotomy is the definitive treatment for Acute compartment syndrome (ACS). When performed in time, it can prevent irreversible ischemic damage to muscles and nerves. The same principles apply to all affected limbs: identify the at-risk limb, act without delay, and completely release all involved compartments to prevent permanent neuromuscular injury.

Introduction

ACS is a limb-threatening condition caused by rising pressure within a closed muscle compartment. The non-compliant fascia surrounding these compartments means that any increase in volume (e.g. bleeding or edema) results in a rapid rise in intracompartmental pressure. Once this pressure exceeds capillary perfusion pressure, ischemia of muscles and nerves occurs.

Fasciotomy is the definitive treatment for ACS, and most clinicians are familiar with a fasciotomy of the lower leg, where the four compartments are decompressed. However, fasciotomy of the foot, thigh, forearm, and upper arm is less commonly taught and often poorly understood, despite the potentially devastating consequences of missed or incomplete release.

Early complications in open fractures

Incidence

ACS most commonly follows high-energy trauma. It may also occur after reperfusion (e.g. following vascular reconstruction or thrombolysis), crush injuries, prolonged limb compression (entrapment), ischemia, or burns. 

Fractures account for approximately 75% of cases, with the highest risk seen in tibial injuries¹, with the highest risk seen in tibial injuries (2–9% of all cases).

Fractures with a higher risk of ACS include:

• Supracondylar humeral fractures
• Segmental fractures
• Displaced forearm shaft fractures
• High-energy distal radius fractures
• Tibial apophyseal avulsions
• Tibial shaft fractures
• High-energy distal tibial fractures

However, ACS may also occur in the foot, thigh, and hand.

This guide provides an overview of the surgical techniques for decompression of the closed osteofascial compartments of the foot, lower leg, thigh, forearm, and upper arm.

General operative technique

1 Use a blade for the skin, and a cautery or blade for the subcutaneous fat. 

2 Incise the fascia with a small stab using the blade.

3 Use closed dissecting scissors under the fascia to push away muscle and other structures in both directions

4 Reinsert the scissors with an open beak and open the fascia along its full length by sliding/cutting through it, keeping the beak open and slightly lifted to avoid damage to underlying tissues.

5 Leave the fascia and overlying layers open to allow swelling.

Upper Arm Fasciotomy

Anatomy

The upper arm consists of two main compartments:

• Anterior compartment, containing the musculocutaneous, median, and ulnar nerves, the brachial artery and veins, and the biceps brachii, brachialis, and coracobrachialis muscles.
• Posterior compartment, containing the radial nerve, the profunda brachii artery and veins, and the triceps brachii (long, lateral, and medial heads).

Fig. 1. The two compartments of the upper arm: anterior and posterior.

Technique

1 Plan the incision
For a medial approach, also known as brachial fasciotomy: Mark an oblique medial incision from the medial epicondyle towards the axilla, approximately 15 to 20 centimetres in length. Identify and protect the ulnar nerve at the medial epicondyle before proceeding deeper.

Fig 2. Medial incision for upper arm fasciotomy

2 Open the anterior compartment (biceps)
Incise the fascia over the biceps and release it longitudinally along the full length of the compartment (see fig 3).

3 Open the posterior compartment (triceps)
Through the same medial incision, identify the medial intermuscular septum and divide it to decompress the posterior compartment (see fig 3).

Fig 3. Opening of the anterior compartment.

Optional posterior incision (triceps)
If the posterior compartment remains tense, make a longitudinal incision between the long and lateral heads of the triceps, extending from just inferior to the deltoid insertion towards the lateral epicondyle. Incise the triceps fascia to complete the posterior release. Take great care proximally, as the radial nerve crosses the posterior humerus and is at risk during deep dissection

Fig. 5-6. Optional direct posterior triceps release.

Forearm Fasciotomy

Anatomy

The forearm consists of three compartments:

• Volar compartment
  o  Superficial layer, containing the median nerve and ulnar nerve, and the muscles flexor carpi ulnaris, palmaris longus, and flexor digitorum superficialis.
  o  Deep layer, containing the anterior interosseous nerve, and the muscles flexor digitorum profundus, flexor pollicis longus, and pronator quadratus.
• Mobile wad, containing the superficial branch of the radial nerve, and the muscles brachioradialis, extensor carpi radialis longus, and extensor carpi radialis brevis.
• Dorsal compartment, containing the posterior interosseous nerve, and the muscles extensor digitorum communis, extensor digiti minimi, extensor carpi ulnaris, abductor pollicis longus, extensor pollicis brevis, extensor pollicis longus, and extensor indicis.

Technique

1 Plan the incision
Start distally in the palm and mark the incision crossing both the carpal tunnel and Guyon’s canal. Curve towards the radial side at the mid-forearm, then continue proximally along the anterolateral aspect of the forearm (see Fig. 2). If needed, extend the incision proximally in line with the same anterolateral trajectory across the elbow.

The carpal tunnel must be formally released as part of the forearm fasciotomy. Fully release the transverse carpal ligament starting with a scalpel, followed by extension with scissors to ensure complete decompression.

Fig 7-8.  Anterior dermato-fasciotomy incision

2 Open the superficial volar compartment
Incise the skin along the marked line. Continue by opening the fascia with scissors to decompress the superficial volar compartment.

Fig 9. Opening of the superficial volar compartment.

3 Open the deep volar compartment
Retract the radial artery, the superficial branch of the radial nerve, and the brachioradialis laterally. Identify the pronator teres, which overlies the proximal radius. Develop the dissection along its ulnar border to access the deep volar compartment. Bluntly dissect down to the deep volar fascia, then incise it to decompress the deep volar compartment. 

Take care to identify and protect the median nerve, which lies in close proximity.

Fig. 10. Opening of the deep volar compartment.

4 Open the mobile wad
Through the same incision, retract the brachioradialis and the extensor carpi radialis longus and brevis laterally. Incise the fascia to decompress the mobile wad. Take care to protect the superficial branch of the radial nerve throughout the release.

5 Open the dorsal compartment
Mark and incise the skin over the dorsal forearm. Open the fascia with scissors and decompress the dorsal compartment in line with the incision.

Fig 11. Opening of the dorsal compartment.

Thigh fasciotomy

Anatomy

The thigh consists of three compartments, with muscular content varying proximally to distally:

Fig 12. The three compartments of the thigh at a mid femoral level.

Mid femur

• Anterior compartment, containing the femoral nerve and femoral vessels, and the sartorius, vastus medialis, rectus femoris, vastus intermedius, and vastus lateralis muscles.
• Medial compartment, containing the obturator nerve and profunda femoris vessels, and the adductor longus, adductor brevis, adductor magnus, and gracilis muscles.
• Posterior compartment, containing the sciatic nerve and profunda perforators, and the biceps femoris, semitendinosus, and semimembranosus muscles.

Fig 13. Mid-thigh compartments: a. anterior compartment. b. medial compartment. c. posterior compartment.

Technique

Two incisions are required to decompress all thigh compartments: a long lateral incision and a medial incision (See fig. 14).

1 Plan the incisions
Mark the lateral incision from the greater trochanter to the lateral femoral epicondyle, and mark the medial incision from the adductor tubercle proximally along the line of the adductor magnus tendon (see fig. 15).

Fig 15. Lateral (a) and medial (b) fasciotomy incisions for the thigh.

2 Lateral fasciotomy
Make a longitudinal incision from the greater trochanter to the lateral femoral epicondyle. Incise the fascia lata and iliotibial band along the full length of the wound, then split them to expose the vastus lateralis (see Fig. 6).

Fig 16. Incision of the skin and  fascia lata.

Gently elevate the fascia from the surface of the vastus lateralis and retract the muscle anteromedially (see Fig. 17 ). Incise the fascia over the vastus lateralis approximately 1 cm anterior to the lateral intermuscular septum to decompress the anterior compartment (see Fig. 18).

Fig 17. Separation of the fascia from the vastus lateralis
Fig 18. Incision of the fascia over the vastus lateralis

Elevate the vastus lateralis from the lateral intermuscular septum and the linea aspera (see Fig. 9). Identify the profunda perforators as they cross the septum, and ligate or coagulate them carefully to maintain haemostasis (see Fig. 19).

Fig 19. Elevating the vastus lateralis
Fig 20. Ligating perforators crossing the septum

Finally, split the lateral intermuscular septum longitudinally along the full length of the incision to decompress the posterior compartment (see Fig. 21).

Fig 21.  Decompression of posterior compartment

3 Medial fasciotomy

Make a longitudinal incision along the adductor magnus tendon, beginning at the adductor tubercle and extending proximally as required (see fig. 15) . Distally, identify the sartorius and vastus medialis, and protect the saphenous nerve and vein. Continue proximally to expose the vastus medialis and adductor magnus. At deeper levels, identify and protect the femoral artery and vein deep to the vastus medialis (see Fig. 22)

Fig 22.  Deep dissection, identifying a. the sartorius, vastus medialis, saphenous vein and nerve. b. femoral vein and artery.

More proximally, identify the rectus femoris, vastus medialis, adductor longus, and adductor magnus, while safeguarding the femoral neurovascular bundle throughout the dissection. Perform a complete longitudinal fascial release of the medial compartment and the fascia over the vastus medialis to decompress both the medial and anterior compartments.

Fig 23.  Decompression of the medial and anterior compartments

Ensure full-length fascial release, incomplete medial release risks persistent compartment pressure.

Lower leg Fasciotomy

Anatomy

The lower leg consists of four compartments:

• Anterior compartment, containing the deep peroneal (fibular) nerve, anterior tibial vessels, and muscles tibialis anterior, extensor hallucis longus, extensor digitorum longus, and peroneus tertius.
• Lateral compartment, containing the superficial peroneal (fibular) nerve and peroneus longus and brevis muscles.
• Superficial posterior compartment, containing the gastrocnemius, soleus, and plantaris muscles.
• Deep posterior compartment, containing the tibial nerve, posterior tibial and peroneal vessels, and muscles tibialis posterior, flexor digitorum longus, and flexor hallucis longus.

Fig. 24. The four compartments of the lower leg: anterior, lateral, superficial posterior, and deep posterior compartments.

Technique

1 Plan the incision
Mark two long fasciotomy incisions, approximately 15–20 cm in length. The anterolateral incision provides access to the anterior and lateral compartments. The posteromedial incision allows decompression of the superficial and deep posterior compartments.

Fig 25. Incision planning for lower leg fasciotomy.
Fig 26. Incision for lower leg fasciotomy.

2 Open the anterior and lateral compartments
Make an anterolateral incision approximately 2 cm anterior to the fibular shaft, beginning roughly 3 cm distal to the tibial crest and extending towards the lateral malleolus. Identify and release the anterior compartment fascia, then open the lateral compartment by dividing the anterior intermuscular septum.

Fig 27-28. Release of the anterior and lateral compartments through the anterolateral incision.

3 Open the superficial and deep posterior compartments
Make a posteromedial incision approximately 2 cm posterior to the medial tibial border, extending towards the medial malleolus. Release the superficial posterior compartment fascia. Identify the soleus bridge and incise it longitudinally to enter and decompress the deep posterior compartment. Take great care in the distal third of the incision, where perforating vessels from the posterior tibial artery are at risk.

Fig. 29. Release of the superficial and deep posterior compartments through the posteromedial incision.

Foot Fasciotomy

Anatomy

The foot consists of six compartments:

• Medial compartment, containing the medial plantar nerve and the abductor hallucis and flexor hallucis brevis muscles.
• Central compartment, containing the flexor digitorum brevis and flexor digitorum longus tendons.
• Lateral compartment, containing the lateral plantar nerve and the abductor digiti minimi and flexor digiti minimi brevis muscles.
• Adductor compartment, containing the adductor hallucis (oblique and transverse heads).
• Four interosseous compartments, dorsally located between the metatarsals, containing dorsal and plantar interossei.
• Calcaneal compartment, containing quadratus plantae and at risk in calcaneal fractures due to bleeding and compression of the plantar neurovascular bundles.

Fig. 30. Five of the six main compartments of the foot: medial, central (superficial), lateral, adductor (deep) and four interosseous compartments.

Technique

1 Open the interosseous and adductor compartments
Make dorsal incisions just medial to the second and lateral to the fourth metatarsal shafts. Open the fascia to decompress the interosseous compartments. 

In the first web space, release the adductor compartment deeply to ensure decompression.

Fig 31. Release of the interosseous and adductor compartments through dorsal incisions.

2 Open the medial and central compartments.
Make an incision along the abductor hallucis. Elevate the muscle to expose the medial compartment fascia and release it. Continue more deeply to decompress the central compartment in continuity.

Fig 32. Medial incision and release of the medial and central compartments.

3 Open the lateral compartment
Make a small incision plantar to the fifth metatarsal. Release the fascia over the abductor digiti minimi and the flexor digiti minimi brevis to decompress the lateral compartment.

Fig. 33. Release of the lateral compartment.

Aftercare

Postoperative splintage

Position the limb in a neutral functional posture to prevent contractures, particularly when muscle damage has occurred. Avoid circumferential splints or casts; use open splintage with elevation.

Delayed surgical closure

When swelling has subsided, the wound is clean, and skeletal stabilization is secure, proceed with delayed closure strategies. Only skin should be closed, deeper tissues/fascia should not be sutured/closed.

Options include:

• Progressive closure using elastic vessel loops through skin staples
• Negative-pressure wound therapy (VAC) to reduce edema and optimize wound bed
• SSG (split-thickness skin graft) for stable coverage when primary closure is not possible

Fig 34-35. Elastic vessel loops

Complete closure without grafting may be achievable once soft-tissue swelling resolves, particularly in pediatric patients. Secondary closure can be performed after graft-take if grafted initially.

Terminology

• Intra-articular distal tibial fracture – fracture of the distal tibia extending into the tibiotalar joint, commonly called a pilon fracture.
• Extra-articular distal tibial fracture – fracture of the distal one-third of the tibial shaft without extension into the ankle joint.
• Delta frame – a triangular modular external fixator configuration commonly used in distal tibial fractures to provide temporary stabilization while bridging the ankle joint.

Trauma mechanism 

Open distal intra-articular tibial fractures are commonly caused by high-energy trauma, including road traffic accidents, falls from height, occupational injuries, sports injuries, and interpersonal violence. These injuries predominantly affect young adults, more frequently males.

Because these fractures are open and involve the articular surface, they carry a substantial risk of infection, which can negatively affect outcomes. Prompt, appropriate soft-tissue management is therefore essential.

Management in the ER

General initial management principles apply:

Initial evaluation and management in open fractures in the ER

Specific points for open distal tibial fractures are:

• Vascular status – Palpate the dorsalis pedis and posterior tibial pulses before and after realignment, and proceed to urgent surgical exploration if pulses remain absent.
• Neurological examination – test the deep peroneal nerve (EDL/EHL), tibial nerve (FDL/FHL), superficial peroneal nerve (dorsal foot sensation), and sural nerve (lateral foot sensation).
• Compartment syndrome – Consider and manage accordingly if pain persists despite adequate analgesia on the reversed WHO pain ladder.

Temporary stabilisation in the ER can be achieved posterior back slab. If displaced, reduce by traction before splinting. Temporary calcaneal pin traction is a less commonly used alternative.

AP and lateral imaging of the lower leg and foot is essential to identify associated injuries of the calcaneus, talus, Chopart joint, or Lisfranc joint.. A CT, if available, is useful for planning definitive fixation and is often obtained after temporary spanning with an external frame.

Fracture management plan

How to make an Open Fracture Management plan

Non-operative management

As with other open fractures, there is generally no place for definitive non-operative treatment in open distal tibial fractures. Intra-articular (pilon) fractures in particular require accurate reduction of the articular surface, which cannot be achieved or maintained non-operatively. Only undisplaced extra-articular fractures with minimal soft-tissue damage (Gustilo-Anderson grade 1) could be considered for non-operative management. In very limited resource settings where internal and/or external fixation is unavailable, it might be your only option, even for less favourable fracture patterns.

Non-operative management consists of immobilization with a posterior below-knee splint, followed by conversion to a circular below-knee cast once swelling has reduced. Given the limited soft-tissue envelope over the distal tibia, non-operative stabilisation is only feasible if the soft tissues allow a cast; a window in the plaster can be used for wound care where needed. Confirm unchanged alignment during follow-up, as reduction close to the ankle joint is easily lost. Conversion to a walking cast can be considered after about 6–8 weeks, with close follow-up during mobilization. Alternatively, calcaneal pin traction can be used to stabilize open fractures when there is significant soft-tissue injury.

Non-Operative Management of open fractures

Operatieve management

For distal tibial fractures involving the ankle joint, plate osteosynthesis is generally the preferred definitive treatment. In extra-articular fractures with sufficient distal bone stock (typically >4 cm proximal to the ankle joint), intramedullary nailing is usually preferred. Both internal fixation strategies should only be performed in settings with adequate surgical resources, limited wound contamination, and reliable soft-tissue coverage – through primary closure or flap reconstruction – in the same procedure.

Because soft tissues are often severely compromised in distal tibial fractures, a two-stage strategy is frequently preferred: temporary stabilization with a modular external fixator, often combined with temporary soft-tissue coverage using vacuum-assisted therapy, followed – preferably within one week – by conversion to internal fixation with plate osteosynthesis together with definitive soft-tissue coverage using locoregional or free flap reconstruction.

In selected patients unsuited to internal fixation, or with delayed soft-tissue recovery, external fixation may serve as definitive treatment; ring fixation is generally preferred, although in practice the initially applied modular fixator is often used until union. In low-resource settings without internal fixation or advanced soft-tissue reconstruction, external fixation may likewise serve as the definitive strategy – when applied correctly, with adequate stability, this can achieve union without infection, although ankle motion may remain limited.

Amputation
Below-the-knee amputation should ultimately be considered and discussed with the patient in cases of severe fractures with vascular injury, or extensive soft-tissue damage such as crush necrosis. In both high- and low-resource settings, limb salvage in these circumstances often means prolonged, complication-prone treatment, whereas amputation with appropriate prosthetic fitting can offer a shorter, more predictable recovery and, for some patients, a better ultimate quality of life

External fixator for a distal tibial fracture

General principles of external fixation apply:

Applying a temporary external fixator

When applying an external fixator for a distal tibial fracture, follow some specific considerations:

• Safe zones - Keep tibial pins within recognised safe zones, staying medial to the tibial crest on the anteromedial side of the tibia to avoid the tibial artery and deep peroneal nerve, at an angle of up to 20° anterior to posterior relative to the sagittal plane. Use a vertical reference line drawn from the medial malleolus to the plantar edge of the heel. A pin can be inserted medially in the area shown below.

• Construct choice - A modular fixator is preferably applied above the ankle joint to preserve ankle motion, following the standard tibial-shaft technique described in Applying an External fixator — possible only when distal pins can be placed safely in the distal tibial segment without violating the joint. When the fracture involves the ankle joint, or safe distal tibial pin placement is not possible, an ankle-joint-spanning modular external fixator — a triangular delta frame — is indicated instead
• Delta frame - place two 5–6 mm half pins in the tibial midshaft (near–far principle), and a transcalcaneal pin — a 5 mm centrally threaded pin from medial to lateral through the posterior calcaneus, one finger-breadth anterior to the posterior edge and one finger-breadth cranial to the plantar surface (use the uninjured foot as a reference if swelling obscures landmarks). Protect the flexor tendons and neurovascular structures, and use a soft-tissue protector before drilling.

Adding stability 

1 Add an additional pin in the first metatarsal shaft (or medial cuneiform/talar neck), connected to the anterior bars, keeps the foot in a neutral position.

2 Maximise pin spread within each bone segment;

3 Use the thickest pins (6 mm) and bars the system allows;

Technical considerations

Plan ahead - Position pins with future definitive fixation and soft-tissue reconstruction in mind. One connecting bar can be temporarily removed at the wound site to improve access during repeat debridement.

Drill guide - Use a tissue protector for drilling.

Soft Tissue Management

The reconstructive ladder is helpful in deciding your strategy. Start with the simplest effective option, but do not oversimplify.

Soft tissue management in open fractures

For small to medium-sized defects with exposed bone, local transposition or rotation flaps may provide reliable coverage. For larger defects of the lower leg, some locoregional options include:

How to perform a gastrocnemicus flap

How to perform a soleus flap

Aftercare

Postoperative rehabilitation

1  Pin-site care – Because of the soft metaphyseal bone, pins loosen more easily in the proximal tibia, and their proximity to the knee raises the risk of septic arthritis if infected – good pin-site care and monitoring are essential.

2  Early mobilization /  Weight-bearing – 

3 Follow-up - Close clinical follow-up is essential; functional recovery can continue for up to a year, particularly in complex cases, with physiotherapy focused on knee and ankle range of motion to prevent long-term stiffness. Complications of fracture management in open fractures

Aftercare after modular external fixation

Complications of fracture management in open fractures

Terminology

• Proximal tibial fractures (PTFs) include both intra-articular and extra-articular fractures of the upper portion of the tibia.
• Tibial plateau fractures are intra-articular fractures of the weight-bearing articular surface and can be classified with the Schatzker classification.
• A more recent, three-dimensional three-column model (medial, lateral, posterior) is especially useful in complex PTFs with posterior involvement, helping surgeons see where fragments are, how they got there, and how they should be repositioned and fixated.

Trauma mechanism

Proximal tibia fractures are often caused by road traffic accidents. Other mechanisms include falls from height, industrial accidents, and assaults.

The mechanism often involves axial loading combined with valgus or varus stress on the knee. A valgus force primarily affects the lateral tibial condyle, while a varus force tends to collapse the medial condyle. A flexed knee is more likely to injure the posterior column. In extension, the anterior column tends to be involved.

Due to the tibia’s subcutaneous position and limited soft tissue coverage, these injuries are highly prone to extensive soft tissue damage, with an increased risk of infection.

Specific management in the ER

General initial management principles apply, as described in:

Initial evaluation and management in open fractures in the ER

Specific points for open proximal tibia fractures are: 

• Vascular status – Palpate the dorsalis pedis and posterior tibial pulses. If absent, realign immediately. If still absent, proceed to urgent surgery.
• Neurological assessment – Evaluate active movement and sensation to light touch.
• Compartment syndrome – Consider and manage accordingly if pain persists despite adequate analgesia on the reversed WHO pain ladder.

Early complications in open fractures

Temporary stabilisation in the ER can be achieved with an upper leg cast or skeletal traction with a pin through the calcaneus.

AP and lateral imaging of the knee and lower leg is essential to initial management. A CT, if available, is useful for planning definitive fixation and is often obtained after temporary spanning with an external frame.

Fracture management options

How to make an integrated open fracture treatment plan

Once the patient has been stabilized, a definitive fracture management plan should be made, weighing: non-operative treatment, immediate definitive fixation, and a staged approach – depending on fracture type, stability, soft tissue status, and available resources. The primary goal is stable fixation that maintains alignment, restores the articular surface, and preserves a functional limb.

Both intra,- and extra-articular proximal tibia fractures can present as unstable. Stability is assessed by grading displacement, articular involvement and cortical continuity.

The AO/OTA classification defines three main types of proximal tibial fractures:

• Type A: Extra-articular – e.g. avulsion of the intercondylar eminence.
• Type B: Partial articular – e.g. split or depression fractures of a single condyle.
• Type C: Complete articular – e.g. bicondylar or comminuted tibial head fractures.

Non-operative management

In general in open fractures of the proximal tibia there is no place for definitive non-operative treatment. Only undisplaced fractures with preserved joint stability and minimal soft tissue damage (Gustilo-Anderson grade 1) could be considered to manage non-operatively. Although in very limited resource settings where internal and/or external fixation is unavailable, it might be your only option.

Non-operative management consists of immobilization with a posterior long leg splint (above knee splint), followed by conversion to a circular above-knee cast once swelling has reduced. Non-operative fracture stabilisation will only be possible if the soft-tissues allow a cast. Sometimes a window in the plaster can be used for wound care. Confirm unchanged good alignment during follow-up. Conversion to a walking cast can be considered after about 6-8 weeks, with good follow-up during mobilization. Alternatively, calcaneal pin traction can be used to stabilize open fractures when there is significant soft tissue injury.

Non-operative management of open fractures

Operative management

Unstable or displaced proximal tibia fractures require reduction and definitive stabilisation, preferably with internal fixation using screws and plating. If soft tissues cannot be directly closed after debridement, or if the expected risk of infection is high, temporary knee-bridging external fixation is advised untill soft tissues are fully healed. With severe prolonged soft tissue compromise or a need for gradual deformity correction in case of older/non-united fractures, definitive fixation using external ring fixation is the preferred treatment modality of choice.

^{External ring fixator}

Absence of local expertise or resources for these procedures should prompt referral, if possible with temporary stabilisation. If referral is not possible, definitive treatment with external fixation can be considered, but should be recognized as suboptimal, carrying higher risk of non/mal-union, joint stiffness, or post-traumatic arthritis.

Definitive fixation with an external fixator

Acute tibia and fibula shortening belong to the treatment options that can be considered in case of bone loss or extensive soft-tissue damage in limited resourced settings. Be aware of the risk of acute vascular compromise due to arterial kinking when shortening larger segments.

Amputation

Above/through-knee amputation should ultimately be considered and discussed with the patient in cases of severe intra-articular fractures with vascular injury, or extensive soft-tissue damage such as crush necrosis. In both high- and low-resource settings, limb salvage in these circumstances often means prolonged, complication-prone treatment, whereas amputation with appropriate prosthetic fitting can offer a shorter, more predictable recovery and, for some patients, a better ultimate quality of life.

External fixator for a proximal tibial fracture

General principles of external fixation apply:

Applying an external fixator

When applying an external fixator for a proximal tibial fracture, follow some specific considerations: 

• Safe zones - Insert pins within the recognized femoral safe zones to avoid injury to surrounding structures including the common peroneal nerve, deep peroneal nerve, and popliteal artery, and to prevent intrasynovial pin placement.

• Construct choice - If possible, keep the fixator below the knee to reduce the risk of irreversible stiffness. In most cases this is not possible, as the proximal fragment is too small to allow safe pin placement, making a knee-bridging external fixator the only viable option. When the proximal fragment is sufficiently large, a reversed delta frame can be used instead. 
• Knee-bridging construct - For a knee-bridging construct, place femoral pins (antero)laterally into the midshaft and tibial pins in the midsagittal plane, ≥15 mm distal to the joint line. 

Adding stability 

For the proximal tibia, the standard bar-to-bar construct is not always stable enough. Depending on the fracture pattern, consider to:

1 Add a neutralisation bar (from the distal femoral pin to the proximal tibial pin, for knee-bridging constructs) or an AP pin in the proximal segment (for a reversed delta frame, avoiding the patellar tendon and posterior neurovascular bundle);

2 Maximise pin spread within each bone segment;

3 Use the thickest pins (6 mm) and bars the system allows;

4 If needed, add a medial accessory frame to resist varus forces, through an open approach with great attention to the popliteal neurovascular structures.

Technical considerations

• Reduction - Closed reduction via ligamentotaxis is usually adequate; control with fluoroscopy if available.
• Knee position - If open reduction is performed, keep the knee neutral or slightly flexed (~10°), never hyperextended.
• Drill guide - Use a tissue protector for drilling.
• Duration - A knee-bridging frame immobilises the joint; minimise the time it stays in place to limit stiffness.

How to manage the soft tissue

The reconstructive ladder is helpful in deciding your strategy. Start with the simplest effective option, but do not oversimplify.

Soft tissue management in open fractures

For small to medium-sized defects with exposed bone, local transposition or rotation flaps may provide reliable coverage. For larger defects of the distal femur some locoregional options include:

How to perform a Anterolateral Thigh Flap

How to perform a gastrocnemicus flap

How to perform a soleus flap

The reconstructive ladder is helpful in deciding your strategy.  Start with the simplest effective option and escalate to flaps if necessary.

Soft tissue management in open fractures

For proximal tibia soft tissue defects, a localregional flaps are a reliable choice, options include:

• Medial fasciocutaneous flap
• Medial gastrocnemius flap 

Open Proximal Tibia Fracture Gustilo-Anderson Grade II - Managed with gastrocnemius flap

In the case of a bone defect or a combined chronic defect, a local pedicled fibula graft, used for combined osseous reconstruction and soft tissue coverage, can offer a valuable solution. These are advanced reconstruction options.

Grade 3B Open Tibia Fracture With Segmental Bone Loss - Uganda

Aftercare after treatment with external fixator

1  Pin-site care – Because of the soft metaphyseal bone, pins loosen more easily in the proximal tibia, and their proximity to the knee raises the risk of septic arthritis if infected – good pin-site care and monitoring are essential.

2  Early mobilization – Restart knee movement as soon as possible to avoid severe stiffness; keep the leg elevated and monitor closely for compartment syndrome during the first 48 hours – patients with open fractures remain at risk despite the open wound.

3  Weight-bearing – Restricted after fixation of intra-articular fractures and resumed gradually. Extra-articular, simple fractures may allow early weight bearing in the frame, with conversion to a long leg cast once healed. Intra-articular or multifragmentary fractures are generally delayed until 6–8 weeks; the frame may stay 3–6 months or be exchanged at 6–12 weeks for a cast or hinged knee brace. Significant knee stiffness is to be expected.

4 Follow-up - Close clinical follow-up is essential; functional recovery can continue for up to a year, particularly in complex cases, with physiotherapy focused on knee and ankle range of motion to prevent long-term stiffness. Complications of fracture management in open fractures

Terminology

• Distal femoral fractures include injuries within the Heim square, a square constructed using the maximal condylar width.
• This text will focus on open distal femur fractures in adults. For pediatric distal femur fracture considerations, further reading is advised at the AO surgery reference website.

^{Distal femoral zone as defined by the Heim square.}

Trauma mechanism

Open distal femur fractures are often the result of high-energy trauma and affect young, otherwise healthy patients. Typical mechanisms include motorcycle or car accidents (dashboard injuries) or falls from height.

The classic mechanism is a direct blow to a flexed knee. Axial load transmitted through the tibia drives the femoral condyles apart, producing a supracondylar intra- or extra-articular fracture pattern.

Several strong muscle groups contribute to the typical shortened, varus-aligned, and posteriorly angulated displacement seen on presentation:

• Shortening – the quadriceps and hamstrings pull in opposite directions.
• Varus angulation – the adductor magnus draws the distal fragment medially.
• Apex-posterior deformity – the gastrocnemius pulls the distal fragment posteriorly.

^{Shortening of femur caused by pulling of quadriceps and hamstrings muscles, and posterior dislocation of the the distal fragment caused by pulling of the gastrocnemius muscle}

Immediately posterior to the distal femur lies the popliteal neurovascular bundle. Due to this close relationship, markedly displaced or open injuries may compress, stretch, or lacerate the popliteal artery, potentially threatening the limb.

Management in the ER

General initial management principles apply.

Initial evaluation and management in open fractures in the ER

Specific points for open proximal tibia fractures are:

• Bloodloss - In open distal femoral fractures, blood loss can exceed 1000 mL, with a real risk of hemodynamic instability or shock.
• Realignment and temporary stabilization - Options include a Thomas's splint, a long-leg backslab, or an improvised splint using available firm materials, secured with bandages or strips of cloth while maintaining gentle traction. Whichever method is used, pad generously around the fibular neck to protect the common peroneal nerve.

^{Thomas’s splint.}

• Vascular status - Palpate the dorsalis pedis and posterior tibial pulses before and after realignment, and proceed to urgent surgical exploration if pulses remain absent.
• Skin status - Perform a thorough evaluation of the skin to assess the possibility of an open fracture.

Temporary stabilisation in the ER can also be achieved with an upper leg cast or skeletal traction using a proximal tibial pin.

Once the patient is hemodynamically stable, start imaging the entire limb, including the joints proximal and distal to the suspected injury. The distal femur is best visualised with anteroposterior and lateral views.

Fracture management plan

How to make an integrated open fracture treatment plan

Once the patient has been stabilised, a definitive fracture management plan should be made. The choice between non-operative treatment, immediate definitive fixation, or a staged approach should be carefully considered.

Nonoperative management

Non-operative management can be considered for stable, minimally displaced, non-articular distal femoral fractures. Always perform surgical debridement in case of open fractures. In low-resource settings, if non-operative management is used for displaced or unstable fractures, a limited functional outcome should be expected.

Operative management

In most cases, especially in high-resource settings, internal fixation is feasible at the first surgery as soon as the patient is stabilised. Alternatively, a two-stage approach can be chosen when soft tissues do not allow direct definitive internal fixation, or when the patient is hemodynamically unstable in a damage control setting. Apply a fracture-spanning external fixator for temporary stabilisation. If a plastic surgeon is available, early consultation and collaborative surgery is recommended.

Open reduction and internal fixation is, in acute open distal femur fractures, the gold standard using locked plate fixation and screws. Fractures without articular involvement can be managed with intramedullary nailing, as described in Open Femur Shaft fracture. Further reading on ORIF is advised at the AO surgery reference website. Open reduction and internal fixation should only be performed once the fracture has been:

• debrided and cleansed,
• when soft tissue coverage in the same early setting is achieved,
• when the environment is sufficiently sterile,
• and when resources and knowledge are available.

When these conditions cannot be met and referral isn't possible, external fixation can serve as definitive treatment.

Definitive fixation with an External fixator

Where resources allow, a proximal tibial pin is the preferred site for tibial skeletal traction (e.g. Perkin's traction). Keep the leg in slight flexion to relax the gastrocnemius and reduce posterior displacement, and continue traction for 6–12 weeks with gradual weight-bearing once union is visible on radiographs. If surgical resources become available, patients treated initially non-operatively should be reassessed for possible conversion to definitive fixation.

_{Early active knee mobilization after the acute phase in Perkin's traction.}

Not all distal femoral fractures are suitable for Perkin's traction

^{Fracture patterns suitable and unsuitable for Perkin's traction}

If surgical resources become available, patients treated initially non-operatively should be reassessed for possible conversion to definitive fixation.

Non-Operative Management of open fractures

Amputation

Above-knee amputation should be discussed with the patient for severe intra-articular fractures with vascular injury, or extensive soft-tissue necrosis. Limb salvage in these cases often means a long, complication-prone rehabilitation; amputation with good prosthetic fitting can offer a shorter, more predictable recovery and, for some patients, a better quality of life.

External fixator for a distal femoral fracture

General principles of external fixation apply:

Applying a temporary external fixator

When applying an external fixator for a distal femoral fracture, follow some specific considerations:

• Safe zones - Keep femoral and tibial pins within recognised safe zones, avoiding the common peroneal nerve, deep peroneal nerve, and popliteal artery, and out of the joint. This means maintaining a (antero)lateral approach femorally, and staying in the midsagittal plane tibially.

• Construct choice - In extra-articular fractures with a large enough distal femoral fragment for two firm pins, a non-bridging fixator can be used instead, as described for Open Femur Shaft fracture. In all other distal femur fractures, the frame must bridge the knee.
• Knee-bridging - Place femoral pins (antero)laterally into the midshaft, one proximal and one distal in the same coronal plane. Place tibial pins just below the anterior tibial tubercle in the midsagittal plane, ≥15 mm distal to the joint line, one proximal and one distal in the same plane.

Adding stability
For the distal femur, the standard bar-to-bar construct is not always stable enough. Depending on the fracture pattern, consider to:

1 Add a neutralisation bar from the distal femoral pin to the proximal tibial pin;

2 Maximise pin spread within each bone segment;

3 Use the thickest pins (6 mm) and bars the system allows;

4 If needed, add a medial accessory frame to resist varus forces, through an open approach with great attention to the femoral artery and other nearby neurovascular structures.

Technical considerations

• Reduction - Closed reduction via ligamentotaxis is usually adequate; control with fluoroscopy if available.
• Knee position - If open reduction is performed, keep the knee neutral or slightly flexed (~10°), never hyperextended.
• Drill guide - The thick soft-tissue envelope around the femur makes a tissue protector essential when drilling.
• Interconnecting bar - Keep it clear of the skin over the knee.
• Duration - A knee-bridging frame immobilises the joint; minimise the time it stays in place to limit stiffness.

Soft tissue management

The reconstructive ladder is helpful in deciding your strategy. Start with the simplest effective option, but do not oversimplify.

Soft tissue management in open fractures

For small to medium-sized defects with exposed bone, local transposition or rotation flaps may provide reliable coverage. For larger defects of the distal femur some locoregional options include:

How to perform a Anterolateral Thigh Flap

How to perform a gastrocnemicus flap

How to perform a soleus flap

• Vastus medialis perforator flap (knee)
• Medial and lateral gastrocnemius flap

Aftercare

1  Pin-site care – pins loosen more easily in the softer metaphyseal bone, and an infected pin near the knee risks septic arthritis; careful pin-site care and monitoring are essential.

2  Mobilisation – knee mobility is inevitably limited while the frame is in place; encourage movement of all other joints, ideally with a physiotherapist, and begin knee range-of-motion exercises after frame removal. Counsel patients that some residual knee stiffness should be expected after an intra-articular distal femur fracture treated with external fixation.

3  Follow-up – close clinical follow-up is essential; functional recovery can continue for up to a year, particularly in complex cases, with physiotherapy central to regaining knee range of motion.

Complications of fracture management in open fractures

Terminology

• The femoral shaft or diaphysis runs from just below the lesser trochanter to the beginning of the distal femoral metaphysis above the condyles.
• This text will focus on open femur shaft fractures in adults. For pediatric femur shaft fracture considerations further reading is advised at the AO surgery reference website. 

^{Femoral shaft zone} 

Trauma mechanism

Open femoral shaft fractures are often the result of high-energy trauma and affect young, otherwise healthy patients.¹ Typical mechanisms include road traffic accidents or falls from height.

The classic mechanism involves high-energy forces acting on the femur, such as direct impact, bending, or rotational stress. These forces disrupt the shaft and often produce transverse or comminuted fracture patterns.

Associated injuries should always be considered in patients with femoral shaft fractures.

Management in the ER

General initial management principles apply.

Initial evaluation and management in open fractures in the ER

In open femoral fractures, where blood loss can exceed 1000–1500 mL, there is a risk of hemodynamic instability or shock.

Realignment and temporary stabilization is important to reduce this risk. Temporary stabilization techniques include femoral traction splint or skeletal pin traction or damage control surgery external fixation.² Often the fracture is too proximal for casting.

Fracture management plan

In most cases, especially in high resources settings, internal fixation is feasible at the first surgery as soon as the patient is stabilized.

Alternatively a two stage approach can be chosen when soft tissues do not allow direct definitive internal fixation or when the patient is hemodynamically unstable in a damage control setting. Apply a fracture spanning external fixator for temporary stabilization. In some settings traction is an alternatieve treatment option, preferably temporarily, if resources allow. Take into account soft-tissue treatment options and possible future definitive fixation when applying the pins. If a plastic surgeon is available, early consultation and collaborative surgery is recommended.

Open reduction and internal fixation

In acute open femur shaft fractures definitive fixation with intramedullary nailing, either antegrade or retrograde depending on fracture location, is the gold standard treatment. When timely adequate debridement and soft-tissue management are performed, early weight bearing and high union rates can be achieved.³ In specific fracture types, especially when the fractures extends towards the joint, plate fixation is recommended. Further reading on ORIF is advised at the AO surgery reference website. 

Open reduction and internal fixation should only be performed:

1 Once the fracture has been debrided and cleansed,

2 When soft tissue coverage in the same early setting is achieved,

3 When the environment is sufficiently sterile,

4 When resources and knowledge are available.

External fixation

When resources for internal fixation are unavailable (and referral not possible), external fixation can serve as a definitive treatment modality. Follow the advises for definitive fixation with an external fixator.

External fixator for a femur shaft fracture

When applying a definitive external fixator for a femur shaft fracture, follow some specific considerations:

• Open reduction - Often the wound of an open fracture leads to the fracture and debridement all the way to the fracture is needed. Open reduction of the fracture through this wound is facilitated. Your approach is preferably from lateral. If a fresh fracture has no wound leading directly to the fracture site, closed reduction in femur fractures is preferred, but depends on the availability of intra-operative fluoroscopy.
• Stability - The femur is exposed to large deforming forces, so the construct must be sufficiently stable. Use large pins (preferably 6 mm) for diaphyseal fixation. Place the pins on each side of the fracture as far apart as possible (near–far principle) but still in strong cortical bone.
• Safe zones - Insert pins within the recognized femoral safe zones to avoid injury to surrounding structures. Even when using the recommended safe zones, care must be taken when drilling through the second cortex, as important neurovascular structures, such as the sciatic nerve, lie directly posterior to it.

^{Femoral shaft safe zone}

Adding stability
For the femur, the standard temporarily bar to bar external fixation is not always stable enough for definitive fixation. Depending on the direction of the dislocating forces, consider to:

1 Add an extra bar:

2 Add more pins at the lateral side or

3 If needed, additional pins can be placed medially on each side of the fracture and connected with bars to counteract valgus forces. This should only be done through an open approach, with great attention to the femoral artery and other nearby neurovascular structures.

Technical considerations

• Posterior pin placement - If the pins are placed too far posteriorly in the femur, the external fixation construct may interfere with the bed when the patient is lying down.
• Anterior pin placement - If the external fixator is expected to remain in place for an extended period, the pins should be inserted laterally or anterolaterally in the femur. Pins placed too far anteriorly may restrict knee motion and may result in persistent knee stiffness, even after pin removal.
• Drill guide - Due to the thick layer of soft tissue around the femur the use of a tissue protector is important. Both to guide the drill and pin in the right direction but also to avoid damaging surrounding soft tissues. The best is to have a long drill guide (6mm diameter) with an insert with the right diameter for a drill bit (3.5-4.5mm).
• Rotational alignment - There are various ways to control rotational alignment. Intraoperative x-rays can be helpful. A practical method to control rotation is: The anterior superior iliac spine (ASIS), patella, and the second toe web space into a straight line, and compare this with the uninjured leg.

Soft tissue management

The reconstructive ladder is helpful in deciding your strategy. Start with the simplest effective option, but do not oversimplify.

Soft tissue management in open fractures

For small to medium-sized defects with exposed bone, local transposition or rotation flaps may provide reliable coverage. For larger defects of the distal femur some locoregional options include:

How to perform a Anterolateral Thigh Flap

How to perform a gastrocnemicus flap

How to perform a soleus flap

Aftercare

Postoperative rehabilitation

1 Early mobilization – Early mobilization and physiotherapy are crucial for functional recovery and prevention of complications such as joint stiffness or thrombosis. Particularly after external fixation of femoral shaft fractures, knee stiffness (especially loss of flexion or extension) can develop if movement is delayed. Thrombosis profylaxis is commonly recommended until the patient is mobilizing.

2 Pin placement and knee motion – Pin position can influence postoperative mobility. Restrict knee motion could be caused by pins placed too anteriorly. In open fractures, however, pin placement is often dictated by the wound location and fracture configuration and must be balanced with the need for adequate stability.

3 Weight-bearing - Gradual progression to weight-bearing depends on depends on the fracture pattern and the stability of the external fixation construct. More stable frames and simple fracture configurations may allow earlier weight-bearing, whereas complex fractures or less stable constructs require a more cautious approach.

Complications

The femoral shaft is well protected by its surrounding muscles and subcutaneous tissues, which often reduces the risk of soft tissue complications compared to fractures in less muscular regions. However, the substantial forces acting on the femur can lead to secondary displacement if the external fixation construct is not sufficiently stable.

If rotational malalignment is suspected, intra-operative correction should be performed immediately.

Complications of fracture management in open fractures

There are different fixation methods for traumatic lower limb fractures in orthopaedics, both surgical and non surgical. Specifically focusing on the tibia treatment options range from above knee circular pop, open reduction and internal fixation with plate fixation, intra medullary fixation as well as external fixators.

External fixators can be used as a form of temporary fixation or definitive fixation depending on the fracture pattern, soft tissue around the limb and available resources. Two types of external fixators are monolateral (in this wiki platform called ‘external fixator’) and ring fixator. Each has its advantages of use and disadvantages.  

This document will be focusing on ring external fixators, its applications, components, applications, and usage.

Terminology & components

• Circular fixator/frame or ring fixator - These terms are used interchangeably. Also often Ilizarov frame is used as a term, but this means a specific ring fixator with fixed struts. For this text we will use ring fixator as the standard term. 
• Wires - 1.8mm diameter, smooth and ideally with a bayonet eccentric tip. Olive wires come with a stop at the bone interface.

• Half pins - Pins that can be inserted in bone and attached to a ring fixator. In general 5-6mm diameter, with different thread lengths available. Modern pins are hydroxyapatite coated. Hydroxyapatite (HA) is a bioactive calcium phosphate ceramic that’s similar to the mineral component of bone. This coating enhances their biological and mechanical performance at the bone–pin interface, leading to better fixation and reduces pin tract infections.

Ring block - Consists of two rings and four connecting rods and is used to stabilise each bone segment. To optimize stability the distance between both rings should be maximum possible, allowing safe distance from the adjacent joints and from the fracture site. 

Virtual ring block - One ring at one limb segment with pins or wires that equals/approximate the stability of a ring block (further reading under ‘How to use Virtual ringblocks & Half pins’).

Dummy ring - An extra ring for improved stability, that is placed in between two rings in a segment when the distance between 2 rings in a segment that is greater than 160mm.

Wire tensioning - Applied by the wire tensioner instrument coming with the set. The steps of tensioning are: 

1 Tighten the wire fixation bolt at one side (always the side of the olive if present). 

2 On the other side the wire fixation bolt is only finger-tightened. 

3 Apply the tensioner on this side.

4 Tension while keeping the tensioner straight withstanding the forces. General rules of maximum tensioning forces: 

• Closed/full ring 130kg (N/m2)
• ⅝  or open ring 110kg
• Post - also known as Rancho; can be attached with a bolt to a ring to enable the creation of virtual ringblocks inserting half-pins on different levels in the bone segment. It often needs to be used in combination with half-pin fixation bolts depending on specific brands.

Indications & conceptualisation

In theory every fracture of a long bone that requires stabilisation and benefits from axial loading is suitable for fixation with some kind of a ring fixator. In reality it depends on several factors whether you would consider choosing this technique above others. These include fracture pattern and location, soft tissue integrity and cover, wound size &contamination as well as patient host factors.

Ring fixation is a biological fixation method that only allows axial micromotion and eliminates shear motions at the fracture site if applied correctly. It leads to a stable yet dynamic frame that allows the surgeon the options of acute and gradual correction, frame modularity to build as complex a frame as needed, and the ability of the patient to bear weight and move adjacent joints as tolerated. Other advantages include fracture reduction and stabilisation can be performed percutaneously; soft tissue resuscitation by ligamentotaxis; it can assist in soft tissue and bone defect management.¹

Ring fixation is considered an advanced technique nowadays mainly applied in tertiary referral centers in high-resource settings. There exist many different brandspecific variations and instruments. However, the principles go back to basic fracture healing, that with proper training, a basic instrument set and the right case selection could be applied in a lower-resource setting. Ring fixator components can be reused and repurposed safely which can be cost saving in the long run.

We will try to describe these basic principles focusing on lower leg fractures in this chapter. We do not pretend to be complete in any way. In the references we will add more in depth further reading. In comment boxes are considerations and alternatives added.

How to apply a basic ring fixator on a tibial shaft fracture?

Here we describe the technique to apply a basic ring fixator for the stabilisation of a midshaft (open) tibia fracture using classic ringblocks and rigid struts. We go into detail of every step, that is basic knowledge for other paragraphs. In the successive paragraphs we describe the sometimes easier and more forgiving alternative techniques with virtual ringblocks, halfpins and rapid adjustment struts. Aspects of both techniques can be combined for specific indications.

1 Preparation

Surgical planning

“you plan to fail if you fail to plan”.

Obtain radiographs - X-ray images of the AP and lateral including adjacent joints should be available prior to the start of surgery to prepare the surgical steps you are planning to take. 

Planning pin placement - It is paramount for the surgeon to go over the anatomy of the lower leg and understand the safe zones for pin placement as well as the location of the perforating arteries which are essential for lower limb flap options. The aforementioned factors may influence pin placement by the surgeon, ring configuration and struts placement. Being aware of the blood supply to the lower limb and location of the perforating arteries will influence the surgeon's debridement plan, any fasciotomies that may be needed and soft-tissue coverage techniques.

The essential perforators come from the posterior tibial artery 10 & 15cm proximal to the medial malleoulus at the posterior tibial border as illustrated

Performing surgical debridement

Prebuilding the frame

For this technique we advise to prebuild the frame based on preoperative x-rays. The prebuilt frame should consist of the rings and struts including its nuts & bolts. 

The prebuilt frame should consist of a ringblock in the proximal segment. The proximal ring is preferably a ⅝ ring with opening at the posterior side to allow the knee to flex and a full distal ring in the proximal segment. Four long connecting rods that exceed in length to reach the proximal ring of the distal segment are different placed through the ring (figure 3). Some surplus length is advised to allow intra-operative adjustment of the distance between the ring blocks and inter-fragmentary compression. In the distal segment the ringblock consists of two full rings. The proximal ring is placed at 3cm below the fracture zone and the distal ring is placed 1cm above the ankle joint. They are connected with rods at other position then the rods of the proximal segment.. A little excess length is useful to allow length adjustment during surgery. 

Preoperative building of the frame

Example of position of rods in the proximal ring. In essence the rods can be placed anywhere. Also does not need to be symmetrical, as long as the weight bearing axis falls within the 'area of support.²

Positioning of the patient

Supine position with small pillow/elevation under the ipsilateral thigh to neutralize the position of the tibial plateau. 

Some doctors prefer the use of a surgical assist device to securely position the leg and allow room for circular frame application such as the Russell Frame (Innovision copyright)], or a frame can be self-build of a modular external fixation set. 

Minimal equipment needed

Check before the surgical checklist procedure (before the patient received anesthesia) the presence of all materials. Check for adjoining sizes of rings. Make sure the application set matches the brand of the circular frame and has instruments that function properly. Sufficient half pins and wires (both with and without olive) should be sterilized. A general orthopedic trauma set for debridement and reduction is on the table. Prepare material to take at least 4 deep cultures in case of suspicion of a fracture-related infection. 

Pre-wash and sterilize the leg according to local protocol

For a tibia fracture sterilize the field from above the knee and the entire foot. Take into consideration possible soft-tissue reconstructions that may be needed for coverage. 

Marking key-points on the leg

Mark/draw a line along the joint line proximally and distally; Proximal line representing mechanical axis of the tibia and it represents the direction of the reference wire. Draw another vertical line to mark the posterior cortex of tibia.

2 Wound and fracture debridement

Perform a full wound and fracture debridementIncluding deep tissue cultures if indicated.

Performing surgical debridement
Surgical debridement in FRI
FRI treatment plan

3 Preliminary reduction

Perform a preliminary reduction. In principle this should be performed closed. In some cases there is an indication or opportunity (open fractures with soft tissue defect over the fracture) to perform an open reduction.

4 Proximal reference wire

Place the proximal reference non-olive wire transverse in the coronal plane lateral-medial direction, parallel to and 1,3-1,5cm distal from the tibial plateau articular surface. Stab incision at the lateral side, drill wire through first cortex using a powerdrill, to steer hold the wire with the lift hand using an alcohol soaked sponge (which will dissipate the heat generated from drilling), use a mallet to pass wires through the remaining soft tissues and skin till it has equal length on both sides, apply alcohol soaked gauzes around base of each wire.

Each ring block must have 4 fixation points. Usually this is 2 per ring, but in theory could by 1 on a ring and 3 on the other ring of the ringblock.

5 Frame placement

Place the prebuilt frame around the leg and attach the reference wire to the proximal ring, place the wire fixation bolts so that the leg will be centered in the ring. Tension the wire to the  5/8th ring to 110kg.

6 Distal reference wire

The distal reference wire is then inserted distal from the most distal ring. It is placed in the coronal plane, and parallel and at least 1cm proximal to distal tibia articular surface using the technique described above under 3.

7 Attaching and tensioning of the distal reference wire

Attaching and tensioning of the distal reference wire to the distal ring will align the proximal and distal fragments in the coronal plane, but not in the rotational plane. Therefore proper rotational alignment must be achieved before attaching the wire. The wire fixation bolts should be placed in the anterior half of the ring to allow proper correction of sagittal plan angulation. The wire can be tensioned 130kg. 

8 Correct translation malalignment

Correct translation in coronal plane, if still present, by sliding the fragments of the wire till aligned. And to correct sagittal angulation, a rolled towel placed under the fracture site can be useful to maintain position temporarily. 

9 Placement of the remaining rings

Place the remaining rings at the correct distance from the fracture (at least two centimeters, depending on fracture fragmentation and obliquity) by adjusting the heights of the nuts on the rods. And place and tighten a transversal wire in both rings.

To fixate the ring perpendicular to the rods, first tighten the nuts above and below the ring on one rod while all other nuts are not close to the ring yet. Next tighten all others while keeping the ring in the same position.

10 Insert remaining wires

Insert the remaining wires in to create stable rings. In reality, perfectly perpendicularly placed wires is hard to achieve, therefore it is suggested to add minimum 2 more wires per ring at 30-90 degrees divergence with two opposing olives at the remaining wires. Always respect the safe zones of wire placement

Alternatively to wires half-pins can be considered to be placed, especially in the tibial diaphysis these hold well. Read the next paragraph about considerations.

Safe zones and advised wire and half pin placement in the left lower leg. For more into detail reading: Ilizarov - Atlas Insertion transoseous Wires Half-Pins.

11 Rods

Tighten the nuts around the rods. Create fracture compression by tightening the nuts of the second and third ring towards each other.

12 Final x-rays

Try to make full bone projections with intraoperative fluoroscopy (if available) in perfect AP and lateral, to measure axis and possible malalignments.

13 Postoperative planning

Depending on soft-tissue treatment direct weight bearing is allowed. Removal of frame once callus is seen on xray and walking without pain and assistance. If no other complications occur generally after 6-12 weeks. 

Rules of twos ³

How to use Virtual ringblocks & Half pins?

Often addition of a second ring in a segment is not possible due to space restrictions, therefore half pins can be added on posts to create virtual ring blocks. A stable virtual ring block consists of: 

• One full ring
• One wire, sometimes added with another wire
• Two half pins on a post at different levels preferably a 7 hole spread on the posts away from each other. Each pin should be placed through divergent orientation

Half pin insertion technique:

1 Longitudinal stab skin incision

2 Spread with a (small artery) clamp till bone

3 Place tissue protector/drill guide on the bare bone

4 Machine drill with 3.5mm drill bit (high speed) while flushing with saline

5 Remove drill and flush through guide to remove debris

6 Insert manually with T-handle the HA-coated 6mm half pin that should be threaded at least the full course through the bone

7 Apply an alcohol swab around the pin at the insertion (or in case available brandspecific protection rubbers) 

All half pins require pre-drilling to minimize thermal necrosis and pin loosening drill no more than 6 seconds and stop to cool the bone, saline irrigation continuously whilst drilling and lastly irrigate drill hole to evacuate debris from the drill hole. Insert a 6mm (HA coated if available) half pin in the hole manually.

The order of application a virtual ring block: 

1 Place a AP half pin on the tibial ridge (when the proximal ring should be placed close to the knee joint a reference wire in the transcondylar transverse plane anterior to the fibula is preferred, as described above) 

2 Connect to a rancho (often with 3 or 4 holes) and attach the ring (5/8th when close to knee) to it loosely. 

3 Adjust the position of the ring till it is perpendicular to the mechanical axis in AP and lateral view (preferably use fluoroscopy confirmation), then tighten the half-pin fixation bolt and the bolt to fixate the post to the ring. 

4 Add a second half pin on the other side of the ring on a post (also often on a post with 3 or 4 holes). First attach the post to the ring. Put the drill guide of the half pin through the hole of the post to determine its position. Insert pin using the technique described above. The safe zone is generally from the anteromedial side of the tibia. Tighten the bolt to the ring first and second the half-pin fixation bolt. 

5 Add a smooth wire in the transverse lateral to medial direction directly onto the ring and tighten it. 

Full half pin constructs

Full half pin constructs can also be used with equivalent mechanical stability by placing three 60° divergent 6mm half pins above and below a ring spanning a large part of the limb segmen (figure 7)t. 

A six-pin two-ring frame with divergent 6mm half pins is equivalent to a four-ring tensioned wire frame in terms of axial stability and bending resistance while allowing axial micromotion. 

The choice for the use of half-pins, wires or a combination of both can depend on different factors, including location of the fracture (in diaphyseal fractures half-pins are better accepted then wires with less pin irritation/infection), availability of materials and surgeons preference. 

The addition of out-of-plane half pins or wires to any limb segment produces an increase in stability to that particular limb segment. This can be particularly helpful when the segment is short.

Half-pins are often preferred in the diaphysis due to less irritation, loosening and infection.

Rapid adjustable struts instead of rigid rods

Instead of rigid rods, nowadays often adjustable struts are used instead. These are more forgiving in application, a frame does not need to be prebuilt, and some give advanced options such as gradual limb correction. 

Generally there are two types:

• Rapid adjustment struts - These are telescopic struts with multi-angle hinges at both ends which allows quick longitudinal, rotational and angular correction. Three or four of these struts spanning the fracture between two virtual ring blocks will create sufficient stabilisation.

Rapid adjustment struts (Orthofix copyright)

• Hexapod struts - These are six telescopic struts with multi-angle hinges placed in a hexapod form, that are numbered and can be gradually lengthened or shortened to correct alignment or length of a limb. This advanced limb reconstruction process is often supported by computer software of a specific frame brand.

Hexapod struts (Smith & Nephews copyright)

How to apply a spanning ankle frame?

For distal tibia or ankle luxation fractures a stabilisation construct often needs spanning of the ankle joint (figure 10). The primary objective of this strategy is to realign and stabilize the traumatized joint until definitive surgery while facilitating soft-tissue treatment and definitive surgical planning. 

A proximal virtual ring block can be placed on the tibial diaphysis proximal to the fracture using the above described technique with half pins only. The distal virtual ring block is a foot ring. The virtual ringblocks are interconnected with adjustable struts. 

With the knowledge of the abovementioned application principles of a ring fixator, this video can be followed to apply a temporary ankle spanning frame:

This Video and Temporary Circular External Fixation for Spanning the Traumatized Ankle Joint for more information on temporary ankle spanning circular external fixation

A technique to place a foot ring: 

• Draw lines on skin - Horizontal at the height where you plan the ring; divide calcaneus in 3rds, at the posterior 3rd line enter the bone with the olive wire and at the anterior third line exit the bone. 
• First wire - Drill the first calcaneus olive wire from lateral to medial 
• Second wire - Drill metatarsal wire from medial to lateral with the ring in perfect position
• Third wire - Drill second calcaneus olive wire from medial to lateral (at that moment the ring is not movable anymore)
• Attachment - Then attach the long struts to the ring to see how high you want the tibia ring (struts should be half way extended)
• Tibia ring in temporary non-weightbearing ankle spanning frames could suffice with only 2 half pins

An ankle spanning trauma frame

Aftercare of ring fixators

Post-operative care for patients can be divided in the acute setting, intermediate and longterm management.

Acute

0 This is immediately post-operative.

• Patient will have wound care Mx 
• Debulking of any bandage around the frame to access wound
• Frame can be cleaned with saline soaked gauze 
• Opportunity for educating the patient on pin-site care should be taken 
• Patients' pin-site gauze will be changed if it is soaked with blood and alcohol soaked gauze re-applied.
• Patient is do pinsite care. Two different regimes are generally followed: 

1 Daily cleaning and leave open

2 Weekly cleaning and dress with sponge.

• To note skin irritation and rash in the first 72 hours. In this case keep pin sites clean and no direct antibiotics is indicated.
• Patient is allowed to weight bear as tolerated (depending on soft-tissue status, the fracture configuration and if the joint was involved)

Intermediate (> 72 hours post frame insertion)

• Note for infection: pinsites will be red, painful, may see pus draining [ref to “the good, the bad and the ugly pinsite classification system”]

• Re-educate on cleaning pinsites and increase cleaning frequency to twice daily, keep a close eye and see patient weekly
• Consider course of antibiotics for a week when a pinsite infection is suspected

Longterm

• Look out for pinsite infection: Chronic infections seen, pus around pinsites, loose wires and pin, unstable frame and abscess collections
• Note radiological features of fracture related infections
• If infection present patient will need in-patient care with incision and drainage of abscess with re-evaluation of frame stability possibly revision of some pins or wires
• Consider need for deep tissue cultures taken when FRI is suspected. Patient may need a course of antibiotics afterwards.

How to diagnose FRI

"Orthopaedics is not carpentry, it's gardening."

Open fractures present a significant clinical challenge because of their high risk of complications. Exposure of bone to the external environment increases the risk of infection, and together with the associated soft-tissue injury can impair bone healing, resulting in delayed union, non-union, or malunion.

Malalignment 

Malalignment occurs when the bones are not aligned correctly during the reduction process, or secondarily, due to insufficient construct stability. Achieving a perfect anatomic reduction is often not mandatory in extra-articular fractures for good functional outcomes. Minor degrees of varus or valgus angulation, antecurvation (anterior bowing), or recurvation (posterior bowing) are generally acceptable and do not significantly affect function. However, rotational malalignment must be carefully avoided, as it can lead to long-term functional problems.

Malalignment in different planes can occur:

Varus/valgus angulation
(coronal)
Valgus angulation is the inward angulation of the fractured bone segment towards the midline. Varus angulation involves outward angulation away from the midline.

Sarmiento criteria² indicate that varus / valgus angulation up to 5 degrees in a tibia is acceptable.

Anterior/posterior angulation
(sagittal)
Anterior angulation (or apex anterior) occurs when the fractured bone segment tilts forward. Posterior angulation (or apex posterior) involves backward tilting of the bone segment.

Sarmiento criteria² indicate that anterior / posterior angulation up to 5 degrees in a tibia is acceptable. 

Translational malalignment
Translational malalignment refers to sideways displacement of the distal fracture fragment relative to the proximal fragment. The distal fragment can be shifted laterally, medially, anteriorly, or posteriorly.

the Sarmiento criteria² consider less than 50% translational displacement acceptable.

Translation can also lead to secondary shortening.

Rotational malalignment
Improper alignment of bone fragments around their longitudinal axis.

Although it should be avoided, internal rotation up to 15° and external rotation up to 20° in the tibia is sometimes regarded as acceptable. Internal malrotation is especially poorly accepted for activities such as walking and cycling.

To prevent malalignment several principles can help:

• Alignment should be checked clinically during surgery. A practical method to assess limb alignment is to ensure that a straight line can be drawn through the following anatomical landmarks:
  - the anterior superior iliac spine (ASIS),
  - the centre of the patella,
  - the second toe web space into a straight line.
• This alignment should then be compared with the contralateral, uninjured limb.
• Direct visualization of the fracture if an open reduction is performed may help to confirm the correct alignment.
• Intra-operative fluoroscopy - If available, use fluoroscopy to control your fracture reduction and adjust if needed. A useful fluoroscopy protocol to control rotational alignment of tibial shaft fractures is called C-Arm Rotational View (CARV)¹ .

The CT scan of this case, shows more than 20 degrees of internal rotation of the left tibia after intramedullary nailing. The rotational malalignment was revised to an acceptable angle.

Inadequate stabilization

If the fixation is not robust enough, it can lead to excessive movement of the fracture site, hindering the natural healing process and potentially results in a (hypertrophic) non-union. A sign of insufficient fracture stability can be excessive callus formation on a follow-up x-ray.

Different techniques in intrinsic stability:

Absolute stability
Generally speaking only internal fixation with plate and screws will create absolute stability leading to primary bone healing.

Relative stability
Whereas most other techniques, like nailing, external fixation and POP, will create relative stability leading to secondary bone healing with the formation of callus. With appropriate alterations and proper application, external fixation can provide sufficient stability for definitive treatment and allow bone healing.

Modern ring fixation systems can be seen as ultimate forms of enhanced modular external fixation for definitive fracture treatment, including computer assisted options to postoperatively correct for malalignment if needed.

Tip - Tighten the clamps every week on the ward to prevent loosening.

Definitive fixation with an external fixator for tips on strengthening an external fixator.

Skin necrosis

Pressure sores or necrosis may occur at the sites where the external fixator components contact the skin or if the limb expands because of swelling. Placing the bars too close to the skin can lead to pressure ulcers and skin necrosis. Therefore, careful attention to pin and bar placement is essential to minimize the risk of these soft tissue problems. 

To prevent pressure ulcers, consider the following:

• Skin distance - Position the bars at an adequate distance from the skin, ideally two fingerbreadths between the skin and the bar.
• Leg elevation - Elevate the leg for the first few days after surgery.
• Early mobilization - Encourage early mobilization and gentle, non-weight-bearing exercises.
• Regular turning - Implement regular turning and repositioning while in bed.
• Patient education - Provide the patient with thorough instructions for skin care and pressure sore prevention techniques.
• Kickstand - Utilize a vertical support bar, also known as a kickstand, beneath the heel to allow it to hang freely off the bed, reducing pressure on the skin of the heel.

Even with internal fixation, metal directly under the skin can cause pressure of the skin, which may lead to skin necrosis.

Pin tract infections

Two types of pin tract infection can be distinguished in external and ring fixators:

1 Pin site infections
These occur around the wounds where the pin enters the limb. They are mostly superficial. Free loose movement of the skin around the pin will decrease the risk for this. Prompt treatment with antibiotics, and local debridement during wound care, is essential to prevent it from leading to deeper tissue or pin tract infections. If a pin is still fixed, it can often be left in place.

2 Pin tract infections
This infection included a deeper infection along the pin tract extending into the bone, which can ultimately lead to a fracture-related infection. In such cases, the involved pins should be removed and new pins placed in a non-infected location. If microbiological testing is available, obtain samples to guide appropriate antibiotic therapy alongside surgical debridement.

Pin tract infections are primarily caused by bacteria entering the skin at the pin insertion site during or after the initial procedure. Factors such as poor wound care, inadequate sterilization during pin insertion, or prolonged use of external fixators heighten the risk of infection. 

Symptoms include:

• Redness
• Swelling
• Warmth
• Tenderness
• The presence of pus or drainage at the pin site

To prevent pin site and tract infections:

• Adhere to sterile techniques
• Minimize heat generation
• Provide stability to the pins
• Make sure there is no skin tension around the pin by creating a large enough skin incision
• Following pin insertion, thoroughly clean and dress the pin sites

Thermal osteonecrosis
During pin or wire insertion, heat generation must be carefully managed to avoid thermal necrosis of the surrounding bone, formation of ring sequestra, and loosening of the pin, which elevate the risk of bacterial infiltration and potential infection.

Pin loosening

Pin loosening often stems from factors like pin infection or inadequate pin placement (for example mono-cortical) during the procedure. Pin infection weakens the bone-implant interface, increasing the risk of loosening. Inadequate pin insertion contributes to this, impacting fracture reduction and overall success. Careful pin insertion, monitoring for infection, and ensuring proper fixation are crucial preventive measures. 

In case of pin loosening, take the following steps:

• Pin Removal - Remove all involved pins and place new pins in a healthy location
• Debridement - Debride the pin sites in the operating theater, using curettage and irrigation

Fracture related infection (FRI)

Deep infection is one of the most feared complications of open fractures. Many measures can reduce this risk, including safe surgical practice, choosing an appropriate fixation strategy for the local setting, and good postoperative care. When the risk of fracture-related infection is high: for example with severe soft-tissue damage, limited sterility, or significant comorbidity; external fixation, such as a bar-to-bar frame or, if available, a ring fixator, should be strongly considered.

An introduction to Fracture-Related Infection (FRI)

Neurovascular damage

Apart from neurovascular damage at time of injury as seen in Gustilo Anderson class 3C injuries, iatrogenic neurovascular damage is especially a risk in open fracture surgery because the high energy of the trauma has led to tissue damage. This may result in more difficult recognition of anatomical planes and structures. In both casting, internal and external fixation there is risk of nerve (peroneal nerve!) or blood vessel damage. 

For external fixation, understanding safe zones for pin placement and adhering to proper anatomical principles is essential for minimizing the risk of neurovascular complications:

• Correct pin placement technique
• Tissue protector - Use a tissue protector or drill bit during drilling and pin insertion to prevent interference with muscles and neurovascular structures.
• Neurovascular status - Conduct direct postoperative neurovascular checks to assess for any signs of compromise or impairment.

Non-union

Non-union is the failure of a fractured bone to heal despite appropriate treatment and a sufficient time frame. 

Persistent pain, lack of radiographic evidence of healing, and the absence of clinical improvement are indicative of a potential non-union. Diagnostic tools such as X-rays, can help to assess the extent of healing or identify factors contributing to the lack of union.

Non-union can result from various factors, including:

• Excessive movement or distraction/malaligment at the fracture site. This also know as hypertrophic non-union, showing excessive callus formation at the fracture site.
• Inadequate blood supply
• Infection
• The presence of systemic conditions that impede the body's natural healing processes (e.g. diabetes, malnutrition, smoking, chronic illness).

As previously mentioned: "Orthopaedics is not carpentry, it's gardening." The identification of the underlying cause of non-union is essential, as successful treatment depends on correcting the biological or mechanical problem preventing union.

Treatment may include surgical intervention to:

• Enhance bone compression at the fracture site.
• Create more fracture stability for example by adjusting an external frame (in hypertrophic non-unions)
• Enhance blood supply. This may include a vascular work-up.
• Treat fracture-related infections
• Improve patient-specific factors.

Joint Stiffness and Muscle Atrophy

Inadequate reduction of intra-articular fractures and prolonged use of external fixation can lead to joint stiffness and muscle atrophy. Early initiation of rehabilitation exercises can help mitigate these issues. A construct should be strong enough for partial weight bearing.

Modular external fixation is intended as a temporary stabilisation method in high-resource settings. However, in select cases, it may serve as a permanent solution, for example in the presence of persistent infection or in patients with significant co-morbidities that make internal fixation unsafe.

This wiki follows the BAPRAS/BOA guidelines¹ where possible.

Indication

Although a definitive external fixator should be regarded as inferior treatment, it can be used for this purpose in low-resource settings due to limited availability of equipment and implants.

When experience, resources, or adequate sterility are limited in your setting, and referral to a centre with access to internal fixation or circular frames is not possible, consider external fixation as definitive fracture management.

External fixation is not very difficult and materials are relatively cheap. With some modifications to the application of a temporary external fixator it can serve as the final treatment for many open fractures with good clinical outcomes.

In some cases, a fracture may be managed with an external fixator until the soft tissues have healed, after which a plaster of Paris (POP) cast is applied for the remainder of fracture healing. In other situations, the fixator remains in place for the full duration of healing.

Factors influencing the choice of definitive fixation type include:

• The fracture pattern
• The extent and nature of initial contamination
• The timing for definitive soft tissue cover
• The existence of dead space following wound excision
• Patient factors

Temporary external fixation for required resources, procedure steps, pitfalls and aftercare when applying a external fixator.

Modifications to a modular external fixator

The following modifications to modular external fixator can be done to improve construct durability and strength:

• Pin placement - Pin placement rules should be performed precisely, to minimize the risk of pin loosening and pin tract infection. Especially pre-drilling and manual pin insertion is mandatory.
• Use thicker pins to enhance bone purchase.
• Positioning the clamps and bars closer to the bone. Still avoid any pressure to skin to prevent pressure ulcers.
• Adding additional connecting bars bridging the fracture (see figure below).
• Placing more pins in each segment (see figure below).

A double bar construct on the lateral side is placed to increase strength. Medially pins in each segment are placed, under direct vision, and connected with a bar to better counter lever the forces on the fracture

External fixation is mostly used as a temporary fixation awaiting definitive internal fixation.

Temporary external fixation is recommended when definitive stabilization and/or immediate soft tissue coverage cannot be performed at the time of primary surgery.

In resource-limited settings, external fixation may be the best available option for fracture fixation. When adequately applied and handled with appropriate aftercare, it can serve as definitive treatment.

Definitive fixation with an external fixator for practical tips on strengthen a external fixation system so it can function as definitive fixation.

Indications for temporary external fixation

Consider external fixation in the following situations:

1 When there are no possibilities for (direct) definitive fixation. 

2 When the systemic condition of the trauma patient only allows short (damage-control) surgery.

3 High risk of infection:

• Contaminated wounds - e.g. Farm injuries, road accidents with dirt, feces, or water contamination.
• Heavily contaminated fracture site - Where immediate internal fixation could seed infection.
• Delayed presentation - More than 6–8 hours after injury.

4 Severe soft tissue damage:

• Compartment syndrome - Risk of compartment syndrome development.
• Extensive soft tissue injury - e.g. De-gloving, muscle crushing, skin loss.
• Delayed coverage/closure - Wounds that require delayed flap coverage or delayed skin closure.

Advantages of temporarily external fixation

Applying an external fixator provides a stable construct that:

• Prevents fracture site displacement
• Reduces pain
• Lowers fracture-related infection risk
• Allows proper wound care and give soft tissues the opportunity to heal or to demarcate the borders of necrotic tissue

According to the BAPRAS/BOA guidelines, if exchange from external fixation to internal fixation is planned, this should be done as early as possible – preferably within 72 hours of the primary debridement and in the same procedure as definitive soft tissue coverage.¹

Approaches

There are different techniques to provide temporary stability with an external fixation. Many different types and brands of external fixators exist with varying complexities, but the techniques described can be simplified.

We prefer modular external fixation (with a bar-to-bar construct) over a single bar technique and a setting with limited skills available, as it enables easier and better fracture reduction and can be universally applied to different fracture patterns.

Modular external fixation

Synonym = bar-to-bar fixation

The basic principles of modular external fixation technique are:

1 On each side of the fracture, two pins are placed

2 The pins on each side are interconnected with a bar and clamps

3 The two bars on each side of the fracture are then connected with another bar and clamps bridging the fracture

Variations are recommended for different fracture locations and patterns. However, the key feature of a modular external fixation is that it provides stable support for the fractured bone and can be easily adjusted for length, angulation, and position.

Modular external fixation

See Tibia Shaft to read the story of a 62-year-old man who sustained an open fracture of the left tibia and was treated with a external fixator.

Single bar fixation

Synonym = linear fixation

In single-bar constructs, pins are placed all in one plane and connected by a single bar. This configuration provides limited stability and makes adequate alignment of the bones more challenging, As a result, the risk of malunion is higher.

The only practical advantage of single-bar fixation is that it requires fewer components (bars and clamps). Therefore, when resources allow, modular external fixation is preferred, as it provides better control of alignment.

Single bar fixation

Damage Control Surgery External Fixation

In the setting of damage control surgery (DCS), external fixation is the preferred method for temporary stabilization of fractures in severely injured patients. Temporary external fixation provides rapid stabilization of long-bone fractures, which helps control hemorrhage, reduces pain, and facilitates ongoing resuscitation and management of associated injuries. Furthermore, external fixation allows access to soft tissues for wound care and simplifies nursing and intensive care management of polytrauma patients.⁴

Principles with priority in Damage Control Surgery: 

• Procedures should be performed as quickly as possible to minimize operative time, reduce additional blood loss, and limit the physiological burden on the patient, allowing the patient to return promptly to the intensive care unit for continued resuscitation.
• Strategic pin placement with anticipated surgical approaches in mind. In general, pins are preferably inserted in the anteroposterior direction, as definitive fixation methods such as intramedullary nails and plates are commonly applied through lateral or medial approaches.

Certain technical principles of definitive external fixation are less critical in the damage control setting:

• Pin placement through muscular compartments within recognized safe zones may be acceptable if it facilitates rapid stabilization (e.g., transfixing the quadriceps muscle in the femur)
• Self-drilling pins may be inserted without pre-drilling to save operative time, even though this may theoretically increase the risk of thermal necrosis and later pin loosening
• Pins may be placed closer together, for instance by using multipin clamps, prioritizing speed of application over maximal construct stability. A multipin clamp in essence functions as a bar on one side of the fracture.

Definitive fixation is generally expected to be performed within approximately one to two weeks after damage control surgery, once the patient has been physiologically stabilized. Current evidence suggests that conversion from temporary external fixation to definitive fixation within this timeframe does not significantly increase the risk of infection due to pin tract colonization.^5,6

Typical examples of temporary DCS constructs include:

Femur shaft

Knee spanning

Ankle spanning

Resources required

The absolute minimum resources needed for a modular construct are:

• Trauma/orthopedic instrument tray - suitable for adequate debridement and reduction  
• Drill – preferably sterile or with a sterile cover; non-sterile is inferior but possible if an assistant is skilled in drilling
• Threaded pins – at least 4 of sufficient length and diameter
• Bars – at least 3 of sufficient length
• Clamps – at least 4 pin-to-bar clamps (that fit the diameter of the pin and bar of your set), and 2 bar-to-bar clamps (that fit the diameter of the bar of your set)
• Drill bit – preferably 3.5mm for a 5mm pin
• Tissue protector - tissue protector or drill sleeve of the same diameter as the pins inserted (preferably a 5mm drill sleeve with 3.5mm insert to pre-drill through the insert first)
• Blades – preferably both a size 11 (for stab incisions for the pins) and a size 21-24 (for debridement and larger incisions)
• Artery forceps - to dissect to the bone after skin incision for the pin has been made
• Fluid - sterile fluid to cool during pre-drilling
• T-wrench - or hand drill for manual insertion of the pins
• (Allen) key - the right type of key to tighten the clamps

The minimal amount of external fixation materials needed to perform a basic bar-to-bar frame.

External fixation of a tibia shaft fracture: step-by-step

We present here the basic steps of applying a modular external fixation for a tibial shaft fracture. Other fracture locations may require adaptions to these steps.

1 Preparation

Before starting the procedure:

• Imaging - use imaging techniques, such as X-rays, to precisely visualize the fracture and the surrounding anatomy. Have the images readily available in theatre.
• Marking - draw important landmarks and proposed pin locations on the skin. This step ensures accurate placement of pins and improves progress of the procedure.

2 Debridement and preliminary reduction

Prior to pin insertion, perform debridement and initial reduction, either open or closed. This involves grossly aligning and restoring the fractured bone fragments to their anatomically correct positions.

Performing surgical debridement

3 Pin placement

This step involves selecting the pins, choosing a location, making an incision, pre-drilling, measuring pin length, and placing the pins.

A. Select pins

• Diameter: The rule of thumb is that the diameter of the pin should not extend 1/3 of the diameter of the bone. In general 5mm pins are appropriate for the femur and tibia (if the bone allows a 6mm pin it will increase the stability of the construct). For smaller diameter bones, such as the metatarsal bone, a 4mm pin is appropriate.
• Length: The length of the pin depends on the diameter of the bone and the amount of soft tissue. Choose a pin that can span both cortices with its threaded part.
• Type of tip: You can choose from self-drilling, blunt, or sharp pins. We always advise to pre-drill, because any type of threaded pin can be inserted, as long as they are straight. If intra-operative imaging is not available, the safest option is to select a blunt pin.

Six of the various types of pins available

B. Location
Plan ahead where the pins will be placed:

• Outside of the zone of injury.
• In the safe zones of a bone. Inserting pins percutaneously through safe zones reduces the risk of damage to neurovascular structures.²
• Place one pin as close to the fracture as possible, while maintaining a distance of two fingerbreadths from the fracture site.
• Place a second pin as far from the fracture as possible, in strong, healthy bone, in an area with adequate cortical thickness (diaphyseal bone).

When choosing the pin locations, use the safe zones and take into account possible soft tissue reconstruction strategies.

C. Incision
Make a stab incision of around 1cm and dissect bluntly to the bone, for example with artery forceps. Place the tissue protector on the bone. Make sure there is no tissue in between.

Tip - For a 5mm pin use a tissue protector or drill sleeve of 5mm with a 3.5mm insert (5.0/3.5). After drilling, remove only the insert to keep track of the location of the pinhole, and insert the pin through the tissue protector. Then remove the trocar B 3.5mm and the drill sleeve.

D. Pre-drilling
Pre-drill your pins with a sharp drill bit, even if they are self-drilling. Drill on high speed, and cool with sterile fluids (saline) during the drilling. Drill through both cortices, but prevent protruding too far to avoid iatrogenic damage to important structures on the opposite side.

We advise to pre-drill and after that manually insert the pins instead of direct insertion of a self-drilling pin because of the following reasons:

1. Thermal injury. Excessive temperature at the bone–pin interface can cause thermal necrosis, which may contribute to pin loosening or infection³.
2. Bone purchase, might be better with pre-drilled pins.
3. One technique that is always applicable irrespective of the types of pins available.

In damage-control setting when an external fixator is left in place only temporary, direct insertion of pins is acceptable and commonly used. However, in practice in lower-resource settings external fixators are left in place for longer time and techniques used are often suboptimal.

Tip - If you drill on a sloping surface (such as the medial side of the tibia), first point the tissue protector and drill perpendicular to the surface, then adjust the drill to the intended direction as soon as the drill bit has entered the bone.

E. Pin length measurement
A pin should always be placed bicortically. 

A few example methods are listed here to measure or estimate the depth a pin should be inserted when intra-operative fluoroscopy is not available:

• Using a depth gauge after pre-drilling and mark the depth on the pin. Marking on the pin can be done for example with a sterile marker, a dot of blood or by tying a ligature.
• If a depth gauge is unavailable, you can estimate the pin length by stopping to dril when you hit the second cortex (it is the moment you feel more resistance again). Mark the drill length that is inside the bone and add 5mm, as a surrogated for the thickness of the second cortex. This length indicates how far the pin needs to be inserted into the bone. Mark it on the pin you will insert.

F. Pin placement
Use a T-wrench to manually place your pins until they reach the measured depth.

4 Build the construction

Connect the two pins on one side of the fracture using a bar and two pin-to-bar clamps. The clamps should be, by estimation, two finger-breadths away from the skin as the optimum between the possibility for soft tissues to swell and optimal construct strength. Securely tighten these clamps.

Repeat this on the opposite side of the fracture.

Connect the two bars with a third bar that bridges the fracture. Do not yet tighten it fully to facilitate definitive fracture reduction.

5 Definitive reduction

Perform fracture reduction and compression. The surgeon maintains the reduction while the assistant tightens the clamps.

6 Check the construct

• Clamp tightness - Check tightness of all the clamps with the key.
• Skin tension - There should be no skin tension around the pins, otherwise skin infection will occur. If there is tension, consider elongating the incision around the pins longitudinally. 
• Pin tract coverage - Turn a gauze around the pin where it exits the skin. Consider dripping povidone over the gauzes.

Aftercare

Here we describe general points for aftercare after external fixation. Specific considerations for fractures types and soft tissue reconstructions apply.

Monitoring

Close monitoring of the lower leg is essential during the first 48 hours after surgery to rule out compartment syndrome. Keep the leg elevated during this period. Patients with open fractures are at high risk, and compartment syndrome may still develop despite the presence of an open wound.

Regular monitoring of the external fixator site for signs of infection, swelling, or other complications, including pain levels, is crucial.

Effective pain reduction is achieved through both bone stabilization with the external fixator as well the use of the reverse WHO pain ladder, as described in pain management.

Wound and pin care

Wound care is a critical part of open fracture treatment. If dedicated wound nursing is available, their specialized attention addresses potential complications.

For the initial week post-surgery, daily pin care ensures a closely monitored healing trajectory, transitioning to every other day as the wound stabilizes. Gauze with iodine acts as a protective barrier, preventing infections and maintaining a sterile environment. Regular pin flushing further reduces the risk of microbial colonisation. 

Performing wound care

Physiotherapy

Early, non-weight-bearing mobilization is recommended as soon as soft tissues permit, balancing the need to prevent stiffness. Adjacent joints should be trained as soon as possible to prevent flexion or extension lag. Also make sure that patients keep their ankle in a 90 degree position to prevent equinus foot deformity.

Complications of fracture management in open fractures