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A versatile closed external fixator

Jagannath Kammath B*, Praveen Bhardwaj#, Venkatdas ж

*Associate Professor of Orthopaedics
#Assistant Professor of Orthopaedics
жResident, Orthopaedics
Kasturba Medical College, Mangalore, Karnataka, India.

Address for Correspondence

Dr. B. Jagannath kamath
Jyothi Mansion, Opposite Prabhat Theatre,
K. S. Rao Road, Mangalore, India. Pin- 575001.



External fixator in compound fractures with exposed bone is well accepted and time tested. But in cases where the bone is not exposed but internal fixation is not possible external fixators have a role, which is not well documented in the literature. The key to success is not to expose the fracture site. For achieving closed reduction with external fixator only a few options are available which are either expensive or are very cumbersome. We herein describe a versatile external fixator, which can be used to achieve closed reduction. The fixator described over scores its counterparts not only in terms of cost but also in terms of versatility and stability .We recommend this fixator in cases where closed intramedullary nailing for one reason or another is inappropriate.
Keywords: External fixator; closed reduction; versatile; inexpensive.

J.Orthopaedics 2007;4(1)e10


We still have a long way to go before the best treatment for the fracture tibia can be stated with finality (Sir John Charnley).

Last decade has seen a major shift in the principles of fracture fixation from mechanical to biological, rigid to semi-rigid and from open to closed methods of fixation. With the advent and popularisation of C-arm and availability of intramedullary interlocking nails, the above-mentioned principles of closed, biological and semi-rigid fixation are achieved. Intramedullary interlocking nails are used worldwide for closed as well as open fractures of long bones. Yet the problems are not fully solved. Some of the criticisms are violating the medullary canal with a foreign body, technically demanding, introduction of infection in potentially compound fractures, intraoperative hazards of radiation and fat embolism, bending and breakage of implant, tedious and sometimes difficult removal of implant. Hence closed biological fixation by intramedullary interlocking nailing has not answered all the questions, and has made us to rethink about other methods of achieving closed biological fixation.

Role of external fixators in compound fractures with exposed bone is well accepted and time tested. Some of the advantages of external fixator are it being a simple procedure, which can be done quickly in a high-risk polytrauma patient, and it provides with all the advantages of early fixation and maintains good alignment and length of the bone with minimal soft tissue damage. As the pins take purchase in the bone away from the fracture site and do not interfere with the fracture site it decreases the chance of ominous complication like infection and also provides access to soft tissue management. The damage to the perifocal tissue is minimal as there are very few gripping elements in each fracture fragment. The method allows for direct surveillance of the limb and wound status, including wound healing, neurovascular status, viability of skin flaps and tense muscle compartments. Associated treatment (e.g. dressing change, skin grafting, bone grafting and irrigation) is possible without disturbing the fracture alignment or fixation 1. In cases of fracture with head injury, which has an extraordinary propensity for rapid consolidation, the external fixator provides for stable and definitive reduction of the fracture even during the first day with relative modest surgical risk.

The conventional external fixator requires dissection at the fracture site to get a good reduction thus increasing the tissue trauma. Long back in 1952 J. R. Moore said “I appeal- keep the closed fracture closed”, he had a great point in it, now we all know. It will obviously be a great advantage if we can get all the benefits of external fixation without exposing the fracture site. Role of closed external fixator in closed fracture is limited at present to comminuted metaphyseal fractures where the principle of ligamentotaxis is used for achieving closed reduction and alignment. Some of the existing methods of achieving closed reduction by external fixator are by using ring fixator with translation and rotation device in Ilizarov system 2 and reposition device in Oganasean system 3. They are really very cumbersome and non-complaint. Although this has been achieved by an Orthofix, but it is very expensive and has some limitations 4. The design of the Orthofix imposes fixed minimum and maximum distance between the clamps. Also the position and the direction of the pin placement are fixed in relation to each other allowing no flexibility to pin placement 4.

We are describing an external fixator, which has all the advantages of external fixator with an added luxury of obtaining closed reduction. It also allows late adjustment in the reduction and above all can be used to give compression at the fracture site. The surgeon has all the freedom for the pin placement with respect to both, the distance between pins and the plane in which pins are passed. Moreover it is not expensive when compared to other external fixators used for closed reduction. In a seriously injured patient with multiple fractures and high risk for surgery it can even be applied in the casualty without worrying about the quality of reduction, which can be later improved under C-arm guidance or even in the X-ray room.

Description of the device:

This is a unilateral external fixator system whose central body and tubular rods are axially coupled by means of ball and socket joints. On the basis of experienced gained by using other fixators we set our self the following objectives while designing this device:

  • Unilaterality

  • Axial Controlled compression

  • Light weightArticularity in different planes

  • Simplicity of application

  • Simple instrumentation

  • Modularity in using for any site of any long bone in all age groups

The device consists of:

Two rods (Fig. 1a) of unequal size at either ends connected to each other by a central corrective assembly consisting of ball and socket joints at both ends and a central compression and distraction assembly. Each ball and socket joint has a working angulatory capacity of about 30 degrees in all directions. This theoretically makes the device to correct any angulation of the extent of about 60 degree in any direction (Fig. 2). The central distraction and compression assembly allows an axial movement of nearly 2.5 cms (Fig. 3), enough not only to correct the usual overriding or telescoping displacement at the fracture site but also to mildly over-distract the fracture site prior to correction of the angulation or translation at the fracture site. Each of these three components two ball and socket joints and one compression-distraction assembly are independently locked by the hexagonal nuts (Fig. 1B [arrow]).

The design of the central corrective assembly like Orthofix imposes a fixed minimum distance between two pins closest to the fracture site, one each on either side of the fracture. But this has been overcome in our system by providing an additional supplementary Lambda rod (Fig. 1C), which serves two important purposes. Firstly it allows the surgeon to introduce and incorporate an additional pin closer to the fracture site (proximal or distal to the fracture site) in a different plane to enhance the stability of the fixation which is otherwise not possible because of the fixed minimum distance between the two innermost pins closer to the fracture site on either side of the fracture site. Secondly, by virtue of being a supplementary second rod with the shape of Greek word lambda (λ) , purchasing a minimum of three pins (two pins closest to the fracture site on either side of the fracture and the third pin placed in a slightly different plane between the above mentioned pins either proximal or distal to the fracture site) spanning the fracture site it acts as a locking mechanism for the entire central corrective assembly (Fig. 3 & 6), preventing loss of reduction due to accidental loosening of locking hexagonal nuts of the ball and socket joints and that of compression-distraction assembly.



     Fig 1.                            Fig 2.                        Fig 3.              Fig 4.






      Fig 5.                          Fig 6

Figure 1: (A) Two rods of unequal size and central corrective assembly.
               (B) Rods and central corrective assembly assembled.
               (C) Lambda rod
Figure 2: Model showing the amount of translation and angulations which can be corrected by described fixator.
Figure 3: Model showing the amount of compression and distraction which can be achieved be the assembly.
Figure 4: (A-D) Steps of fixator application (Refer text for details).
Figure 5: (A-D) Steps of fixator application (Refer text for details).
Figure 6: Clinical picture showing the fixator in place for one of the cases.


All the cases where intramedullary nailing of the tibia in not possible and the surgeon wants to have all the advantages of closed fixation:

  • Degloving injury with fracture bone not exposed

  • Impending compartment syndromePotentially compound fractures (wound not communicating with the fracture site)

  • Unhealthy skin over the nail entry site

  • A polytrauma patient who is high risk for long anaesthesia it will decrease the duration of surgery.


In order to make best use of fixator, with least exposure to the radiation we recommend the following technique for achieving closed reduction of the fracture shaft of the tibia:

Patient is given general or spinal anaesthesia and placed on a table compatible with C-arm. Under aseptic precautions, two Schanz pins are placed one on either side of the fracture site preferably over the antero-medial surface of the tibia (Fig. 4 A-C). One of these pins can be closer to the fracture site than the other but the distance between the two pins should be at least 1 cm more than the minimum fixed distance determined by the length of the central corrective assembly (in our system this distance is 10 cms) (Fig. 4D) Now an attempt of closed reduction is performed with the help of C-arm (Fig. 5A). The pins on the proximal and distal fragments can be used as joysticks to gently manoeuvre the fragments for closed reduction. Once a reasonable closed reduction is achieved the fixator is applied purchasing the two pins using standard universal clamps with the rods of the fixator, whose two ball and socket joints are in neutral position and the central corrective assembly opened midway (with a provision to compress or distract 1.25 cm on each side). Now with the fracture reduction maintained, the fixator is locked by tightening the hexagonal nuts (Fig. 5B). Now the third and fourth Schanz pins are introduced in the proximal and distal metaphyseal region in the site and direction suitable for the particular case (Fig. 5C). Once all the four Schanz pins are placed, the fine tuning of the closed reduction can be obtained by loosening the nuts of both the ball and socket joints. Compression or distraction can be achieved without loosening of the nuts of the ball and socket joints. Additional purchase of the skeleton using a Lambda rod is now achieved by introducing a separate Schanz pin closer to the fracture site proximal or distal to the fracture site (Fig. 5D). This Lambda rod will take purchase at this eccentric pin and at least two pins, one on either side of the fracture site. This Lambda rod thus locks the central corrective assembly and also enhances the mechanical fixation by virtue of being between the skeleton and the central corrective assembly of the fixator (Fig. 6).

Alternatively this eccentric Schanz pin for the Lambda rod may be introduced following the introduction of first two pins and before the application of the fixator. This may be preferred because it will be difficult to pass the eccentric pin in the diaphyseal cortical bone with the universal clamp used as drill guide without disturbing the fracture reduction. For mechanical reasons this eccentric Schanz pin is introduced on that side (proximal or distal) of the fracture site which has a greater distance between the fracture site and the Schanz pin closest to the fracture site. Similar procedure can be used for the metaphyseal fractures by using a transverse metaphyseal fractures by using a transverse metaphyseal clamp on the smaller metaphyseal fragment.

Though we are not claiming for any originality of the method or the principle, to the best of our knowledge we have not come across any external fixator being used for closed reduction incorporation tubular system and universal clamps.


We do not recommend this external fixator in cases of segmental fractures, fractures with bone loss and metaphyseal fractures with intra-articular extension.


  1. Kovafix External fixator system. Surgical technique instruction manual. The Coimbatore Surgical Pvt. Ltd., BB Street, Coimbatore India.

  2. De Bastiani G, Aldegheri R, Brenzi Brivo L. Dynamic axial external fixation. Clinical Orthopaedics, India; 1990; Vol.5: 160-177

  3. Woods GW. General principles of fracture treatment. In Campbell’s Operative Orthopaedic. 9th ed. Cannale TS. Mosby. 1998: 2669-2723.

  4. Galyakhovsky Vl, Frankel VH. Operative Manual of Ilizarov Technique. 1st Indian ed. Peter L Ferrace. Jaypee Brothers. 1994.


This is a peer reviewed paper 

Please cite as : Jagannath Kammath B:A Versatile Closed External Fixator

J.Orthopaedics 2007;4(1)e10





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