COMPANION ANIMAL PRACTICE

External skeletal fixation can be used to manage a wide range of simple and complex fractures

Practical guide to linear external skeletal fixation in small animals

SANDRA CORR

EXTERNAL skeletal fixation is a very adaptable technique that can be used to stabilise a wide variety of fractures. A basic frame can be applied using relatively inexpensive equipment, and confidence in the procedure can be quickly gained by starting with simple fractures and applying straightforward principles. As familiarity with the technique increases, frames can be used to manage more complex fractures and angular limb deformities, or for temporary transarticular fixation to protect ligament repairs or manage severe soft tissue shearing injuries. This article discusses a step-by-step approach to external skeletal fixation and unravels some of the associated terminology.
Sandra Corr graduated from Glasgow in 1985, and spent six years in small animal and equine practice. She subsequently worked at the University of Zimbabwe as a lecturer in small animal surgery for two years, before returning to the UK to undertake a PhD in xxx? at the Roslin Institute and a residency in orthopaedics at Glasgow. She is currently a lecturer in small animal surgery at the Royal Veterinary College.

EQUIPMENT

BASIC COMPONENTS
The original external skeletal fixation system is the Kirschner-Ehmer system (Veterinary Instrumentation). Subsequent improvements, primarily in clamp design, have been incorporated into the second generation Securos (Orthomed) and IMEX-SK (Animalcare) systems. Many components are interchangeable between the systems, and the principles of application of a generic fixator are the same, irrespective of which system is used. The exception is the acrylic pin external fixation (APEF)

system (Veterinary Instrumentation), where the pins are set into an acrylic column rather than clamped to a metal or carbon bar (see box on pages xxx and xxx).

FRAME SIZE
As a broad guideline for the original Kirschner-Ehmer system, it is recommended that the small system be used for animals weighing 5 kg, the medium system for animals weighing between 5 and 30 kg, and the large system for animals weighing >30 kg. While these are useful guidelines, the basic rule to follow is that pin size should be chosen first, and this should not exceed 25 to 30 per cent of the bone diameter. This will subsequently determine the choice of clamps and connecting bars, taking into account factors such as the fracture configuration, expected healing time, and the level of activity that an animal undertakes. A list of component sizes for the different systems is given in the table on the facing page.

The basic frame

A basic external skeletal fixation frame is created from pins driven percutaneously into the bone, and attached to one or more connecting bars placed outside the body. This type of fixation has the following distinct advantages: As the implants bridge the fracture site externally, rather than internally, closed fracture reduction is often possible, thereby better preserving the biological environment of the fragments and surrounding tissues; The external frame can be adjusted to improve fragment reduction and alignment based on postoperative radiographs; The stiffness of the frame can be reduced as healing progresses, to increase loading on the fracture.

FRAME SHAPE
A frame consists of multiple pin-clamp units, and the fundamental principle is that every pin must pass through two cortices to function. A half pin passes through one skin surface only to attach to a bar on one side, while a full pin passes through both skin surfaces, connecting to a bar on both sides. The terminology used to describe the resulting constructs is based on whether there is a connecting bar on one or both sides of a limb, and whether the bars are in single or multiple planes. In general, type Ia frames are weaker than type Ib frames, which are weaker than type II frames, which are weaker than type III frames (see illustrations on pages xxx and xxx). Truly bilateral frames cannot be used above the elbow or stifle due to the presence of the
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(left) External skeletal fixation clamps. (A) Standard Kirschner-Ehmer clamp, (B) Securos clamp, (C) IMEX-SK clamp. Loosening the nuts enables Securos and IMEX-SK clamps to be attached to a connecting bar at any stage of frame construction; this is not possible with the standard Kirschner-Ehmer clamp. (above) IMEX-SK clamp attached to a radiolucent carbon fibre connecting bar

External skeletal fixation pins are made of hardened stainless steel, and are stiffer and more resistant to bending than Steinmann pins. (A) Negatively threaded Ellis pin. The threads are cut into the shank, making the pin relatively weak. The weakest point is the thread-shaft junction (arrow), which must be protected within the medullary cavity. (B) Smooth pin (trochar point). (C) Positive-profile pin. The thread diameter is greater than the shank diameter, making this type of pin stronger than Ellis pins. (D) Centrally threaded positiveprofile pin. (E) End-threaded positive-profile pin

(C)

EXTERNAL SKELETAL FIXATION SYSTEM SIZES Clamp size Kirschner-Ehmer Small Medium Large Small Medium Large Miniature? Small Large Pin shank diameter 20-24 mm 30-32 mm 40 mm 16-24 mm 24-32 mm 32 mm 09-24 mm 24-40 mm 28-48 mm Connecting bar diameter 32 mm 48 mm 80 mm 32 mm 48 mm 95 mm (CF) 32 mm 63 mm (CF+T) 95 mm (CF+A)

body wall, although a type I frame is too weak to resist the forces produced by the combination of limb loading and the large muscle masses in these regions. The basic type I frame can be strengthened for such applications by tyingin an intramedullary pin. Another modification of the type I frame is the transarticular fixator (see page xxx).

Securos

IMEX-SK

FRAME STRENGTH
As with any implant, the type of frame that is chosen must be strong enough to resist the forces acting on the fracture, as determined by the fracture configuration and the bodyweight of the animal (see box on the right).

Connecting bars come in a range of lengths and are made of stainless steel, except where indicated. CF Carbon fibre, T Titanium, A Aluminium

Increasing the strength of an external skeletal fixator-bone construct

Increase load sharing with the bone by minimising the fracture gap Increase the component size. This essentially relates to pin size, which should not exceed 25 to 30 per cent of the bone diameter. Pin stiffness is proportional to pin diameter4 Increase the number of pins (three to four pins in the most proximal and distal fragments) Use full pins instead of half pins Minimise the bone to clamp distance. Pin stiffness is inversely proportional to pin length3. A shorter pin-clamp distance also aligns the frame closer to the biomechanically stronger central axis of the bone. However, it should be possible to insert a finger between the skin and the clamp to prevent postoperative swelling from causing pressure necrosis of the skin Add extra connecting bars

APPLICATION OF A BASIC GENERIC FRAME

Routine preoperative investigation and stabilisation of a traumatised animal should be performed prior to general anaesthesia and fracture repair. Analgesia should be provided and the limb externally coapted, where appropriate, to improve comfort and minimise swelling. It is difficult to adequately support fractures of the femur or humerus with external coaptation, and these are better left unsupported.

STAGE 1. FRACTURE PLANNING

Fracture configuration should be assessed using well positioned and correctly exposed orthogonal radiographic views of the limb. Care must be taken to identify any fissures that could split on pin insertion. A fracture plan should be made by tracing the fragments and then reconstructing the bone, enabling a scaled plan of the repair to be drawn (see page xxx). This avoids much of the guesswork in deciding where to place the pins, especially following a closed reduction. It is also advisable to have a plan B (ie, an alternative frame or fixation method)! Towel forceps should be clipped onto a toenail or through a sterile bandage wrapped around the foot, instead of onto the interdigital skin which can tear easily. The limb is suspended just above the table until surgery begins, at which point the table can be raised slightly to support the animals weight.

STAGE 3. APPLYING THE FIXATOR

Pins must be placed through safe corridors, as described by Marti and Miller (1994a,b), to avoid major neurovascular tracts, muscle masses and tendons. Careful palpation of the bone helps to identify these areas. Care should be taken to avoid placing pins into growth plates in immature animals. Inadvertent joint penetration can be avoided by placing hypodermic needles into the joint spaces to act as markers.
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STAGE 2. PREPARATION
The patient should be prepared for surgery as normal. Positioning the animal using the hanging limb technique is recommended (see page xxx), as this helps to realign the fracture, and stretch and fatigue the muscles.
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A sharp skin incision should be made with a number 11 scalpel blade, and the soft tissues separated down to the bone by blunt dissection using mosquito forceps. Failure to create a large enough portal results in the soft tissues binding up around the drill bit or pin. Ideally, soft tissues should be protected using drill guides or small Gelpi retractors.
Applying the pins

Place the most proximal and distal pins first, preferably parallel to the adjacent joint surfaces.

Attach the connecting bar(s). If standard KirschnerEhmer clamps are being used, the bar(s) must be preloaded with the appropriate number of clamps, as determined in the fracture plan. With the Securos or IMEX-SK kits, or if Kirschner-Ehmer split clamps are being employed, clamps can be added to the bar(s) at any stage. Insert the remaining pins through the clamps. Ideally, a minimum of six cortices should be engaged in the main proximal and distal fragments. Threaded pins should be inserted parallel to each

(above and below) Type Ia external skeletal fixator. This unilateral, uniplanar frame is the weakest configuration, and is only suitable for simple fractures in small dogs and cats

(above and below) Type Ib external skeletal fixator. This unilateral, biplanar frame configuration is composed of two unilateral type Ia frames, usually positioned at 90 to each other. It is a relatively weak construct and is used for simple fractures in small dogs and cats; however, it can be made stronger by linking the frames proximally and distally

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other, and perpendicular to the bone. This is easiest, most biomechanically sound, and makes the best use of the bone stock. Non-threaded pins should be placed at 70 to the bone to increase pull-out resistance. Pins should be no closer than three times their diameter to a fracture line or joint surface. If bone stock is limited, it may be necessary to bridge a joint (eg, the distal tibia and the tarsus-proximal metatarsus) or to use an adjacent bone (eg, the proximal ulna if the proximal radius is fractured).

The pin-bone interface

Assuming that the clamps remain tight, the security of the frame depends primarily on the pin-bone interface. This can fail either due to thermal necrosis created during pin insertion, or as a result of excessive local stresses on the pin, or a combination of both. These problems can be minimised by following the rules listed in the box on page xxx.

STAGE 4. POSTOPERATIVE RADIOGRAPHY

Orthogonal views should be taken to assess: FRACTURE ALIGNMENT AND REDUCTION. If this is sub-

(above and below) Type II external skeletal fixator. This bilateral, uniplanar frame is stronger than those pictured on the previous page and is used for more complex fractures. The presence of the body wall limits its use to below the elbow and stifle. The frame has at least one full pin per proximal and distal segment, with two connecting columns that span the fracture and connect the fixation pins. The number of full pins can be varied to create frames of differing strengths, making this the most commonly applied configuration

(above and below) Type III external skeletal fixator. This bilateral, biplanar frame is the strongest configuration. It is composed of a type Ia frame linked to a bilateral frame (usually placed at 90 to each other). This type of fixator is most useful for severely comminuted fractures of the tibia. Pins can be linked to connecting bars using single or double clamps

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Modifications of the basic frame. (A) Tied-in frame. The intramedullary pin is placed first to align the fragments, and then bent over and linked to a type I frame (either directly or using a separate connecting bar), considerably increasing the frame strength. This type of configuration is most commonly used for fractures of the humerus and femur, but is also applicable to the tibia. (B) Transarticular frame, which has been applied to temporarily immobilise the elbow following reduction of a luxation of the radial head. (C) Transarticular A frame. An extra bar attaches the proximal and distal ends of a transarticular frame to resist large bending forces. When using transarticular and A frames, the joint must be set at a functional angle to allow limb use, and the frame should ideally be removed within three weeks

optimal, some adjustment is possible by loosening the clamps and manipulating the pins; PIN POSITION. Pins that are not correctly seated in the trans-cortex can be adjusted aseptically in the radiography room by loosening the clamp and advancing or retracting the pins using the drill. Pins that are too close to fracture or fissure lines, or joint surfaces, should be removed and replaced in theatre.

STAGE 5. IMMEDIATE POSTOPERATIVE CARE

Bandaging should be applied in two layers: An inner layer should be placed between the frame and the skin to reduce skin movement and swelling, and absorb discharge. Sponges from disposable surgical brushes are ideal; these can be dried and resterilised. This layer is maintained until the pin tracts have stopped discharging (four to five days).

Fracture planning. (A) Radiograph showing a comminuted fracture of the distal tibia and fibula in a cat. (B) Tracing of the fractured bone, outlining the major fragments, which have been measured. The distal fragment was too small to hold three external skeletal fixation pins, so the decision was made to reconstruct the bone using lag and positional screws, and protect the repair with a transarticular frame. (C) Plan showing reconstruction of the bone and the position of the screws. (D) Postoperative radiograph of the fracture reconstruction; this can be useful to check the position of the screws and the external skeletal fixation pins before the connecting bars are attached

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Preserving the bone-pin interface

The heat generated during drilling can be minimised by using a low speed, high torque drill to insert smooth and Ellis pins directly. The drill speed should be as slow as possible to avoid excessive heat production, but still enable smooth pin advancement without excessive wobble (50 to 150 rpm). A pilot hole should be drilled using a slightly smaller drill bit, prior to insertion of positive-threaded pins. Hand-drilling is not recommended as unavoidable wobble tends to produce too large a hole. Local stresses on individual pins can be reduced by: Increasing the number of pins per fragment and spreading them as evenly as possible along the length of each fragment; Using threaded pins, which have a larger area of bone-pin contact that spreads the stresses; Using thicker (ie, stiffer) pins. Thinner pins bend more and may overload the cis-cortex.

A second (outer) layer covers the frame at all times to decrease the likelihood of the frame catching and being pulled off, and to protect the owners legs and furniture! The distal limb should also be bandaged for the first 24 to 48 hours to reduce postoperative swelling. Thereafter, the distal limb should be left undressed to encourage the animal to use the leg, and any swelling should be relieved by gentle massage. Owners should be advised to monitor the pin sites; some redness and swelling is to be expected in the first week, along with mild serosanguineous discharge. Excessive or prolonged discharge, especially if discoloured, indicates pin tract infection or pin loosening, both of which are associated with increased lameness. Owners should be asked to restrict dogs to short, lead walks while the fixator is in place.

Hanging limb technique. The leg remains suspended after being prepared and draped

Insertion of proximal and distal pins, with hypodermic needles marking the tibial border of the stifle joint

leading to delayed or non-union with a generalised loss of bone mineral density. This can be addressed by staged disassembly of the frame, with or without bone grafting.
Staged disassembly

STAGE 6. FOLLOW-UP ASSESSMENT

Radiographs should be taken three to four weeks postoperatively in immature animals, and six weeks in adults or sooner if there is concern about progress. Clinical union often occurs before radiographic union is evident, so clamps can be loosened and the fracture site manipulated to determine if the fracture is stable.
Bone healing

A major advantage of using external skeletal fixation is that surgical invasion of the fracture site is not required to obtain anatomic reduction and alignment. The soft tissues and vascular supply to the fragments are thereby preserved. As a fracture gap usually remains, interfragmentary compression is rarely achieved and, therefore, secondary (indirect) bone healing results. The stronger and more stable the frame, the less callus formation is seen radiographically. While a certain amount of axial micromotion creates beneficial strains across the fracture gap, excessive axial motion or bending, twisting and shearing forces are detrimental to fracture healing. Thus: An overly weak frame will result in excessive callus formation and potential premature pin loosening and failure; An overly strong frame can result in excessive stress protection, where the beneficial microstrains are absent,
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Staged disassembly (or destabilisation) is controlled reduction in the stiffness of the frame to increase loading of the bone. This can be carried out by: Removing individual pins; or Converting a type II frame to a type I frame by removing the connecting bar (and trimming the pins) on one side. The most proximal or distal pin should not be removed, as leaving empty pin tracts in positions not spanned by the frame can produce stress risers (focal concentrations of stress), thus predisposing the bone to fracture through the empty holes. Studies on the effects of destabilisation have produced variable results. It would appear, however, only to have a positive effect on fracture healing when performed between six and 12 weeks after fracture repair (Egger and Histand 1993).

Inner layer of dressing. Polyurethane foam (Allevyn; Smith & Nephew) has been placed around the pins to absorb any discharge and scrub sponges have been used to minimise soft tissue movement and swelling

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COMPLICATIONS

Most complications seen with external skeletal fixation are caused by poor technique. However, these are usually minor, easily dealt with, and rarely produce a negative outcome. PREMATURE PIN LOOSENING is by far the most common complication, and results from a failure of the pin-bone interface. Clinically, a loose pin causes pain, inflammation and discharge from the pin tract, and leads to increased lameness. Radiographically, a radiolucent line is seen around the pin, as bone is resorbed and replaced by fibrous connective tissue. If the pin feels loose after the clamp is undone, it must be removed as it no longer contributes to the frame. If the most proximal or distal

pin loosens and is replaced, the new pin should be placed so that the fixator bridges the empty screw hole. CONTINUED INSTABILITY causes further resorption and can lead to infection or, in extreme cases, sufficient bone weakening to cause fracture. Loosening of a single pin is to be expected, but loosening of several pins suggests that the frame is too weak, or that the surgical technique has been poor. PIN BREAKAGE is rare. CATASTROPHIC FRAME FAILURE occurs only if the required strength of the frame has been seriously underestimated. PIN TRACT INFECTION. If the pin is stable, and only a slight discharge is present, this can be managed by applying basic hygiene measures (ie, cleaning the area, as necessary, using sterile saline and a cotton bud). Infection is

Acrylic pin external fixation system

In the acrylic pin external fixation (APEF) system, the pins are set into acrylic columns rather than clamped to metal or carbon bars. The basic kit consists of a divided pouch containing liquid and powder components, which begin to set on mixing and can be poured into tubular moulds. Care must be taken to prevent acrylic leaking out around the pins and setting on the animal, which can cause burns. Appropriately sized acrylic columns are of equal or greater stiffness and strength to a comparable Kirschner-Ehmer system, as long as sharp bends in the tube are avoided. Recently, epoxy putty has become available (Epoxy ESF Putty; Veterinary Instrumentation) which comes in a semisolid form in a tube; the putty is kneaded for three to four minutes to activate the components, prior to moulding it around the end of pins to form a bar. Advantages The acrylic? tube or putty can be moulded to any shape, allowing great flexibility in the direction of pin placement. This is particularly useful in stabilising jaw fractures, as the frame can be conformed to the curved jaw, and pins angled to avoid tooth roots. Disadvantages The frame cannot be adjusted after the acrylic or putty has set. Temporary clamps and a connecting bar (applied laterally to the empty acrylic tube) can be used to maintain reduction and alignment until postoperative radiographs are taken, after which the acrylic can be applied. However, it is not possible to check clinical union without cutting the acrylic bar, which cannot then be easily reconstructed. NB. Do not be tempted to cut costs by using a blob of acrylic to attach pins to a steel bar this will fracture or loosen rapidly.

APEF system. The green clip is removed, and the liquid and powder mixed. The tubing should be capped at one end (plugs are supplied) and the acrylic poured (or injected) into the tubing while it is still relatively liquid in order to ensure it is distributed along the full length. Air bubbles should be avoided, as pockets of air within the tubing will weaken the column APEF SYSTEM SIZES Kit size APEF Small Medium Large Pin shank diameter 16-24 mm 24-32 mm 32-40 mm Connecting tubing 10 mm 15 mm 21 mm Acrylic pack 50 ml 100 ml 150 ml

Epoxy putty used to link multiple pins into a mini-fixator, which has been applied to stabilise multiple metatarsal fractures in a cat

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most commonly due to coagulase-positive Staphylococcus species, and is predisposed to by leaving a loose pin in place for an extended period of time. Major pin tract infection is rare, and usually resolves when the pin is removed. Consequently, osteomyelitis is also uncommon. In severe cases, infection can extend into the soft tissues and erode through a vessel, resulting in life-threatening haemorrhage. This has been reported with pins exiting the radius medially, with damage to the median artery; in such instances, the pin must be removed and a pressure bandage applied. RING SEQUESTRA are occasionally seen as a result of thermal necrosis, typically from high-speed drilling of dense cortical bone. Treatment involves removing the pin which is loose and curetting the tract using an oversized drill bit. Subsequent drainage leads to uneventful healing.

Radiograph showing lysis and a periosteal reaction around a loose pin (arrows)

(above) APEF fixator used to stabilise mandibular fractures in a boxer. Note that the front bumper bar dips ventrally below the jaw rather than protruding rostrally, which would make it more difficult for the animal to feed and drink from a bowl. (below) Radiograph of a healed rostral mandibular fracture in a similar case to that pictured above, showing placement of the pins at different angles to avoid the tooth roots

Pin tract complications. (left) Soft tissues have become swollen, causing impingement of the skin on the clamps and discharge from the more distal pin. (right) Minor pin tract infection. In this case, the pins remained secure, so the wound was cleaned daily using saline and a cotton bud, and the tract closed uneventfully

COMPARISON OF DIFFERENT SYSTEMS

KIRSCHNER-EHMER SYSTEM
The Kirshner-Ehmer system is cheaper than the Securos or IMEX-SK systems. However, its major limitation is that the components are weaker than those of similarly sized Securos or IMEX-SK kits, and so more complex frame configurations (types II and III) are required for all but the most simple fractures. In addition, there are some specific limitations associated with the clamp design: Standard clamps cannot be added or removed from a frame without dismantling it;
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 Positive-profile pins do not fit through standard clamps, thus restricting their use to the most proximal or distal position in the frame; The two aforementioned limitations can be overcome by using split clamps, although these are inherently weaker; Clamps are designed to fit a specific size of pin, and cannot be repeatedly tightened without deforming them, thus reducing their lifespan (average four to five uses).

COST COMPARISON* FOR EXTERNAL SKELETAL FIXATION SYSTEMS Small Kirschner-Ehmer Single clamp Single split clamp Connecting bar (stainless steel) Ellis pin Trochar pin Securos Single clamp Connecting bar (stainless steel) Connecting bar (carbon fibre) IMEX-SK Single clamp Connecting bar (stainless steel) Connecting bar (titanium alloy) Connecting bar (aluminium) Connecting bar (carbon fibre) APEF Pins Tubing Acrylic Epoxy putty? Medium Large

10.00 14.30 3.52-4.20 3.00 2.50 9.50 1.50-2.00

10.00 14.30 4.66-5.04 3.00 2.50 11.00 2.50-3.00

10.00 14.30 8.10-15.67 3.00 2.50 11.00 2.50-3.00 Not yet available

SECUROS SYSTEM
The Securos system has the following advantages: Clamps are designed to be clipped onto the connecting bar, thus permitting easy addition or removal of clamps at any stage; The connecting frames are stronger; Guides are available for pre-drilling pilot holes and placing full pins; Axial dynamisation is possible using special clamps that grip the pin but slide on the connecting bar. This allows axial loading, but protection against torsion, translation and bending.

10.50 3.90-4.30

13.65 4.30-12.10 4.40-12.40

16.80 5.15-8.40 4.95-14.15

3.00 4.83 16.00 7.50 (55 g)

3.00 6.03 22.51 15.00 (110 g)

3.00 6.03 30.91

IMEX-SK SYSTEM
The IMEX-SK system has the following advantages: Clamps allow any size or type of pin to be added or removed at any stage; Single clamps can be modified to form an adjustable articulation for transarticular frames; Carbon fibre connecting bars are available. These are radiolucent, lighter and considerably stiffer than steel bars; Axial dynamisation is not possible with the IMEXSK system, but staged disassembly can be performed by either: Progressively reducing the stiffness of the connecting bars (titanium, carbon fibre, steel, aluminium in order of decreasing stiffness); Replacing large clamps and rods with smaller ones (eg, at six weeks).

*Approximate cost (July 2004) in sterling for basic equipment (not including VAT). The range of prices is for connecting bars of different lengths. A large variety of pins are available, and costs are comparable between the systems, and so have not been included. Referred to as mini/miniature in the IMEX-SK system

References EGGER, E. L. & HISTAND, M. B. (1993) Canine osteotomy healing when stabilised with decreasingly rigid fixation compared to constantly rigid fixation. Veterinary and Comparative Orthopaedics and Traumatology 6, 182 MARTI, J. M. & MILLER, A. (1994a) Delimitation of safe corridors for the insertion of external skeletal fixator pins in the dog. 1. Hindlimb. Journal of Small Animal Practice 35, 16-23 MARTI, J. M. & MILLER, A. (1994b) Delimitation of safe corridors for the insertion of external skeletal fixator pins in the dog. 2. Forelimb. Journal of Small Animal Practice 35, 78-85 Further reading PIERMATTEI, D. L. & FLO, G. L. (1993) Handbook of Small Animal Orthopaedics and Fracture Repair. Philadelphia, W. B. Saunders KRAUS, K. H., TOOMBS, J. P. & NESS, M. G. (2003) External Fixation in Small Animal Practice. Oxford, Blackwell Science

Equipment suppliers KIRSCHNER-EHMER, APEF,

AND EPOXY PUTTY

Veterinary Instrumentation www.vetinst.com SECUROS Orthomed www.ortho-med.co.uk IMEX-SK Animalcare www.animalcare.co.uk

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