EXTERNAL FIXATION

ANKLE
Preparation
 commonly used for acute management of pilon and unstable
ankle fractures or in presence of compromised soft tissues
 CT performed after fixator to better delineate fracture pattern

 setup OR with radiolucent table and C-arm perpendicular

from contralateral side
Positioning
 supine on radiolucent OR table with feet at end of bed, bump
under ipsilateral hip

 non-sterile tourniquet
Tibial Pins
 tibial pins placed proximal to fracture and just medial to
anterior tibial crest

 ensure placement does not interfere with definitive fixation

Calcaneal Pin
 transcalcaneal pin inserted from medial to lateralstarting
point 2cm inferior to medial malleolus and 2cm anterior to
posterior border of calcaenus
Bar Placement and Fracture
Reduction
 span tibial pins with bar, creating stable base
 connect bars from stable base to calcaneal transfixtion pin
medially and laterally
 check AP/Lat fluoro of fracture site and pull traction while
applying varus/valgus and anterior/posterior force
Postoperative
 non-weight bearing in splint, CT of ankle afterwards

 1-2 wks: serial soft tissue checks, pin site cleanings and
dressings
Surgical Planning
 fixator provides fracture stabilization and soft tissue
ligamentotaxis to allow for decreased articular impaction and
soft tissue swelling
 CT performed after fixator placement to better delineate fracture
pattern and articular injury
 fixator to be left on until swelling resolves and return of skin
wrinkles (10-14 days), can be used for definitive management if
significant comorbidities
 decreased incidence of wound complications and deep
infections with fixator treatment compared to ORIF, can
combine with limited percutaneous fixation using lag screws
Table and Imaging
 setup OR with radiolucent table
 c-arm from contralateral side perpendicular to table, monitor
at foot of bed in surgeon direct line of site
Patient Position
 supine with feet at the end of the bed, bump under ipsilateral
hip to get limb into neutral rotation
 patella pointed towards ceiling, often foot will be externally
rotated through fracture site distally
 thigh tourniquet optional
Approach
 mark out proximal extent of fracture in distal tibia using fluoro
 palpate and mark out tibial crest anteriorly

 on back table prepare trochars, drill guides, and sleeves x2

into horizontal bar connector holes 1 and 4/5
 place trochars firmly on skin to mark distance and location
between skin incisions
Bar Placement and Fracture
Reduction
 place pin-bar connectors to tibial horizontal bars and
calcaneal pins 2-3cm from skin
 size 11 bar connector bolt for tightening needs to be pointed
towards ceiling for later tightening
 estimate bar length needed (i.e. 6’, 70kg male,~450-500mm)

 bar length needs to accommodate fracture reduction and

increased limb length
 add 2 carbon fiber bars in triangle (delta) formation into
system and gently tighten bar connectors for provisional
fixation
Postoperative Care
 Immediate Post-op
 non-weight bearing in splint
 CT of ankle to delineate fracture pattern and articular
comminution
 1-2 Weeks
 non-weight bearing in splint
 serial soft tissue checks, await return of skin wrinkles
 serial pin site cleanings and dressings
 surgical planning for definitive fixator management vs. ORIF /
tibiotalar arthrodesis depending on fracture characteristics and
patient comorbidities
Complications
 pin tract infections
 loss of reduction in external fixator
 ankle stiffness
 nonanatomic restoration of articular surface
 iatrogenic injury to anterior tibial artery, vein, deep peroneal
nerve during tibial pin placement (if placed lateral to medial)