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External Fixation

Bones are strong and somewhat flexible when an outside force is placed on them, but if this force is excessive, the bones can break. There are many kinds of broken bones (fractures). Some fractures are not visible outside the body and some result in the bone piercing through the skin. The latter is referred to as an open or compound fracture. This type of fracture is considered fairly serious due to the risk of wound infection. In this case the bone will also require a surgical procedure called a fixation, where materials like pins and wires will be used to hold the two (or more) parts of the fracture together so the bone can heal.

There are two types of fixation:
  1. External fixation is the stabilization of the fracture by placing pins, screws, and/or wires into the bone on both sides of the fracture and the pins are then secured together outside of the skin using a series of clamps and rods known as the external frame. This technique is used for a serious break that causes injury to soft tissue, muscles, and nerves, making it prone to infection, such as a severe open fracture. This technique can be used as both a temporary or definite treatment. The purpose of external fixation is to:
  • Stabilize the bone if closed reduction fails.
  • Treat the fracture that involves joint dislocation.
  • Treat the pathological fracture.
  • Treat the fracture that involves injury to blood vessels and nerves.
  • Help the patient move around more quickly when they have other injuries to prevent further complications.
Internal fixation is part of a procedure referred to as “open reduction and internal fixation” or ORIF. Surgery is done to visualize the fracture and reposition or reduce the bones so they are aligned. Then plates and screws, intramedullary rods or nails, and/or pins and wires are attached directly to the bone to hold it in place. The purpose of internal fixation is to:
  • Stabilize the fracture.
  • Support the fusion of bone and repair of the injured muscles.
  • Make it easy to clean the open wound.
  • Correct deformities caused by injury of the arms, legs, and hips.
  • Reduce the chance of disability due to injury and tumor growth.
  • Reduces loss of blood to the bone.
  • Reduces injury to the tissue at the trauma site.
  • Provides stability to the fracture.
  • Can be adjusted without requiring further surgery.
  • An option for patients at risk for infection.
  • Hardware is visible outside the body.
  • Limits movement of the joint.
  • Prone to complications if left in place for too long.
  • Hardware is heavy and can be uncomfortable.
  1. Please let the doctor know about all medication that you are taking as some may need to be stopped before the procedure. Blood-thinning medications such as aspirin, Persantin, Plavix, warfarin, Heparin, and Fraxiparine have to be stopped at least one week before the procedure or as recommended by the doctor.
  2. You will undergo a thorough health examination that will include blood tests, x-rays, and electrocardiogram (EKG), as recommended by the doctor.
  3. Get adequate rest before the procedure. Do not smoke or drink alcohol before the procedure as these can increase the risk of complications during surgery.
  4. Please let the hospital or doctor know if you are not feeling well before the surgery, such as if you have a fever or a cold.
  5. You will likely need to avoid food and water for six to eight hours before the procedure or as recommended by the doctor.
  6. The area that will be operated on will be thoroughly sterilized before surgery.
  1. The doctor will prepare the hardware suitable for the type and location of the fracture.
  2. The affected part will be manually extended.
  3. An incision will be made in the skin to place the screw.
  4. Hardware will be attached to stabilize the bone(s).
  5. Procedure is complete.
If the hardware is temporary, once the fracture has healed sufficiently, the doctor will remove the hardware after two weeks or carry out surgery to place hardware internally, in a procedure called an Open Reduction and Internal Fixation (ORIF).
 
  1. After the surgery, you will be moved to the recovery room where you will be monitored closely until the anesthesia wears off. Side effects from general anesthesia may include headache, nausea, and vomiting, which can be managed with medication.
  2. Post-operative pain may be managed with regional anesthesia patient-controlled anesthesia (PCA), which allows you to press a button that administers a specific amount of pain-relieving medication intravenously. Both may have side effects that include nausea and vomiting as well as drowsiness.
  3. While you are on intravenous fluids, you will not be able to eat, but will be allowed to take sips of water. Once the intravenous is removed you will work your way up from a soft diet to normal food.
  4. Activity:
  • Reduced sensation.
  • Extremities feel cold.
  • Pin sites are looser.
  • Increased swelling.
  • High fever that lasts more than 24 hours.
  • Severe pain not managed by medication.
Abnormal symptoms:
  • Elevate the affected area to reduce swelling.
  • Keep the pin sites clean using a sterile method. The area will be cleaned three times a day while you are in hospital and you should clean it once a day when you are home.
  • Clean any discharge from the pin sites using normal saline solution.
  • Do not let the pin sites get wet. When showering, cover the area with plastic.
Caring for the affected area:
  • You are likely to experience some pain in the first few days following the procedure. You will be given pain medication to manage this. If the medication does not alleviate your pain, please let your doctor know.
  • Try to distract yourself from the discomfort by watching television, listening to music, or doing your breathing exercises.
  • After the external fixation device is placed, elevate the affected limb above the level of the heart.
Pain management:
  • Move your arm or leg along with the external fixation. Because you will be limited on the amount of weight you can place on the affected limb, use a trapeze or bedframe to help you move.
  • Do not exercise using the affected limb.
  • Use a walker or crutches when walking unless recommended otherwise by your doctor. When walking with a walker or crutches, be very careful not to fall or slip. Avoid floors that are wet or slippery.
  1. Monitor the site for abnormal symptoms that may signal complications. These symptoms include:
    • Reduced sensation.
    • Extremities feel cold.
    • Increased swelling.
    • High fever that lasts more than 24 hours.
    • Severe pain not managed by medication.
  2. Exercise regularly as instructed by your medical team to speed up healing so you can return home and carry out normal activities. Exercise as much as you comfortably can. If you experience any abnormal effects, such as increased pain or swelling or if the pin sites/incisions become more swollen, those are signs of over exercising or exercising incorrectly. Stop the activity and consult with your doctor and physical therapist. Carefully follow all the instructions of your medical team when you are at home.
  3. After the procedure, when you are home, you must dress your wound(s) once a day. Monitor the area for signs of infection, such as swelling, redness, and/or pus. Keep your wound clean and avoid getting it wet. Return for your follow-up appointment to remove sutures because if they are left in too long, they can become infected. When the sutures are removed will depend on the location and type of incision. For example, an incision in the leg takes 10 to 14 days for the sutures to be ready for removal. Your doctor will give you more information about this.
  4. Keep all follow-up appointments so the doctor can check your wounds and your symptoms as well as recommend physical therapy, exercises, and ways to care for yourself. More appointments will be made until you are completely healed.
  5. Maintain good general health by eating nutritious food. There are no dietary restrictions.
  1. Injury to the nerves and blood vessels due to the pin impacting blood vessels when placed. This must be treated with surgery.
  2. Infection around the pin, which is the most common complication. Thus, it is important to clean the area at least once a day. If the infection is just on the skin, cleaning it and applying antibiotic medication may control the infection. If it reaches the bone (osteomylelitis) and the bone starts to die (ring sequestrum), this dead bone may have to be removed with surgery (sequestrectomy). The pin will also be removed and a new pin will need to be placed in a different location.
  3. Injury to muscles and tendons the pin went through, which can lead to tearing of the tendon or inflammation of the muscles. If many pins are used, they can cause ankle stiffness, which is common in a tibia fracture.
  4. Delayed union, which occurs in 20-30% of patients. The device has to be placed for longer in these cases.
  5. Compartment syndrome refers to the increase of pressure in a closed space that is high enough to interfere with the circulatory system and the function of the soft tissue within that space. This is usually diagnosed when the pressure in the closed space is more than 40 millimeters of mercury (mmHg), but if the pressure is more than 20 millimeters of mercury (mmHg), monitor the patient. Compartment syndrome can occur in the arm or leg where the external fixator is placed. With an open surgery the location is clearly visible, but an external fixation is done using a closed method, which increases the risk of compartment syndrome. It is a common complication if not managed appropriately. This is especially true with injury to an appendage and is frequently found in the arms and legs. Paralysis and atrophy of the muscles of the limbs are a result of lack of blood flow to the muscles due to increased compartment pressure, which affects circulation. The treatment is to decompress the area with surgery or doing a fasciotomy immediately.
  6. Refracture can occur after the fixator is removed if not prevented with the use of crutches, supplemental casts, or other devices, along with the infection of the pin. If the external fixator is placed for more than one week, there is a high chance of infection, especially in patients who will undergo open reduction and internal fixation (ORIF) surgery.
  7. Thrombosis or blood clot in the leg that can break away and move to the lung. This must be treated with medication immediately as it can be a life-threatening complication.
  8. Damage to the nerves and/or blood vessels, which requires additional surgery.
  9. Abnormal pain from surgery, which may increase and affect mobility.
  10. The surgery may affect sensation and the color of the skin where the incisions are made/the pins are placed. In some cases the scarring may appear different from other patients and may be thick, hard, and red, and may be tender to the touch.
The risk of complications is higher in patients who are obese or who smoke. They are more likely to experience infection at the wound as well as the chest, heart, and lungs. They are also more likely to develop blood clots.
 
Before the Procedure
  • The patient will be evaluated and diagnosed by the doctor before surgery is planned and the surgery will take place as soon as possible, depending on the patient’s readiness. This can be one to two days or within 24 hours.
  • It is recommended that you stay at a hotel close to the hospital for convenience in traveling to the hospital before and after the procedure, as recommended by the doctor, for physical therapy and follow-up appointments.
After the Procedure
  • You should plan to remain in Thailand for at least two weeks through the duration of your treatment. This may vary from person to person, depending on your individual health and medical condition before the procedure as well as your age. Certain factors may require a longer stay in Thailand. This does not include the time for physical therapy after the surgery.
  • When you return for your follow-up appointment you will undergo a physical examination and your wound will be checked. You will receive documentation of your treatment history, a medical certificate, follow-up appointment slips, your “fit to fly” certificate, and a Medical Information Card (Bone Card).
  • You may travel by car if it is a four-seater and it is recommended you sit in the passenger seat with the seat reclined. If you are traveling in a van, it is recommended you sit behind the driver and recline your seat.
  • Normally patients can travel home by air. Please discuss this with your doctor to confirm that you are healthy enough to fly before making flight arrangements. If you need a walking aid, such as a walker, crutches, or cane, be sure to let the airline know in advance if you will need a wheelchair at the airport and when you get off the airplane at your destination.
    • If you are traveling in First or Business class:
      • You can recline your seat normally, but support the affected limb to keep it from dangling and to maintain it in normal alignment. Exercise your leg muscles regularly while you are in the air by flexing and pointing your toes. Take 10 consecutive long deep breaths every hour to improve blood circulation.
      • Drink at least 2,000 to 2,500 milliliters of water each day. Avoid caffeine, sedatives, and alcohol. If you have been prescribed venous thromboembolism (VTE) prophylaxis, follow your doctor’s instructions strictly.
      • If your doctor has recommended that you wear a brace or an arm sling, please keep it on for the duration of the flight, except when you recline your seat. You may take it off at that time. If you have an elastic bandage around the affected limb, you may loosen it slightly while in the air.
    • If you are traveling in Economy Class, be sure to select a seat in the exit row or a bulkhead seat.
      • You can recline your seat normally, but support the affected limb to keep it from dangling and to maintain it in normal alignment. Exercise your leg muscles regularly while you are in the air by flexing and pointing your toes. Take 10 consecutive long deep breaths every hour to improve blood circulation. Please get up and move around at least every 30 minutes.
      • Drink at least 2,000 to 2,500 milliliters of water each day. Avoid caffeine, sedatives, and alcohol. If you have been prescribed venous thromboembolism (VTE) prophylaxis, follow your doctor’s instructions strictly.
      • If your doctor has recommended that you wear a brace or an arm sling, please keep it on for the duration of the flight. If you have an elastic bandage around the affected limb, you may loosen it slightly while in the air.
Delayed union occurs in 20-30% of patients and will require the hardware be placed for longer than planned.
 
What if this procedure is not performed?
Some types of broken bones heal on their own, but often they don’t heal correctly, which is why it is important to seek medical treatment to ensure the bone is put back into the right position and heals properly. Complications that can occur without appropriate treatment includes pain caused by a bone that does not heal at all or does not heal well, deformity, bone fragments affecting nearby organs, risk of a broken bone piercing through the skin, inability to walk, and post-traumatic osteoarthritis.
How a broken bone is treated depends on the extent of the injury and your doctor will determine the best treatment to ensure that your bone heals well and you are able to return to normal activities. Other treatment options for broken bones may include cast immobilization, where the broken bone is put back into place and then kept in position with a cast, a functional cast or brace that allows for limited movement of nearby joints, traction, where the bone is aligned using a gentle, steady pulling action, and an open reduction and internal fixation (ORIF), where the skin is opened above the fracture and hardware is attached directly to the bone.

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