surgical fracture treatment, fixation types -...
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SurgicalSurgical fracturefracture treatmenttreatment, ,
fixationfixation typestypes
III. III. ExternalExternal SkeletalSkeletal FixationFixation
dr. Varga Attila
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HistoryHistory of of ExternalExternal
FixationFixation
••AlreadyAlready usedused atat thethe end of end of thethe 19th 19th centurycentury
••GainedGained popularitypopularity duringduring//afterafter II WWII WW
••WidespreadWidespread useuse delayeddelayed ((missingmissing standardsstandards))
••WidelyWidely usedused atat presentpresent ((biologicalbiological osteosynthesisosteosynthesis))
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AdvantagesAdvantages
•• MinimallyMinimally invasiveinvasive
•• RobustRobust mechanicalmechanical environmentenvironment
•• EffectiveEffective inin infectedinfected areasareas asas wellwell
•• DynamizationDynamization atat a a laterlater stagestage of of healinghealing
•• HighlyHighly customizablecustomizable (PMMA/APEF)(PMMA/APEF)
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DisadvantagesDisadvantages
•• OutsideOutside of of weightweight bearingbearing axisaxis
•• Pin Pin tractstracts areare infectioninfection risksrisks
•• SomeSome systemssystems areare notnot „„flexibleflexible”” inin useuse (K(K--E)E)
•• SomewhatSomewhat limited limited rangerange of of orthopedicorthopedic situationssituations
•• CanCan injureinjure patientpatient//ownerowner
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IndicationsIndications
•• TIBIATIBIA
•• RADIUS & ULNARADIUS & ULNA
•• HUMERUS & FEMURHUMERUS & FEMUR ((withwith restrictionsrestrictions))
•• ShearingShearing injuryinjury, , GunshotGunshot traumatrauma
•• SomeSome mandibularmandibular fracturesfractures
•• VeryVery smallsmall patientspatients
•• MatureMature patientspatients/ / ImmatureImmature patientspatients ((growthgrowthplateplate!!)!!)
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TibiaTibia & & RadiusRadius//UlnaUlna
•• ESF most ESF most applicableapplicable toto
–– shaftshaft fracturesfractures
–– highlyhighly comminutedcomminuted diaphysealdiaphyseal fracuresfracures
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HumerusHumerus & & FemurFemur
•• Less Less appropriateappropriate thanthan R & UR & U
–– OnlyOnly unilateralunilateral framesframes
–– ThickThick softsoft tissuetissue coveragecoverage (pin (pin tracttract infectioninfection))
–– BiggerBigger mobilitymobility of of softsoft tissuestissues (ex (ex femoropatellarfemoropatellar
liglig, , quadricepsquadriceps etcetc))
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ShearingShearing injuriesinjuries
•• ESF ESF providesprovides easyeasy accessaccess toto thethe woundwound thusthus
facilitatesfacilitates dailydaily managementmanagement
•• RigidRigid fixationfixation a major a major advantageadvantage inin thethe casecase of of
articulararticular injuriesinjuries
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ShearingShearing injuriesinjuries
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ShearingShearing injuriesinjuries
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ShearingShearing injuriesinjuries
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ShearingShearing injuriesinjuries
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GunshotGunshot traumatrauma
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GunshotGunshot traumatrauma
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GunshotGunshot traumatrauma
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GunshotGunshot traumatrauma
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MandibularMandibular fracturesfractures
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DebridementDebridement
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FixateurFixateur externeexterne
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VeryVery smallsmall & & ImmatureImmature patientspatients
•• VeryVery smallsmall
–– MinimallyMinimally invasiveinvasive
–– PreservingPreserving softsoft tissuetissue & & bloodblood supplysupply
–– YorkshireYorkshire radiusradius, , footfoot, , carpuscarpus//tarsustarsus, MC/MT, MC/MT
•• ImmatureImmature
–– MUST NOTMUST NOT bridgebridge activeactive growthgrowth plateplate
–– LimbLimb elongatingelongating operationsoperations
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BridgingBridging a a jointjoint
•• OnlyOnly maturemature animalsanimals!!!!
•• WhenWhen extra extra placeplace is is requiredrequired toto insertinsert pinspins
•• TemporaryTemporary fixationfixation!!!!
•• KeepKeep jointjoint inin functionalfunctional angleangle!!!!
•• SupportingSupporting a a „„weakweak”” internalinternal fixationfixation
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LimbLimb correctioncorrection osteotomyosteotomy
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ElementsElements of an ESF of an ESF systemsystem
•• FixationFixation pinspins
•• FixationFixation columncolumn ((connectingconnecting columncolumn//rodrod))
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The The differentdifferent systemssystems
•• KK--E E systemsystem
•• SecurosSecuros, , ImexImex--SKSK
•• SynthesSynthes--AesculapAesculap
•• PMMA/APEFPMMA/APEF
•• ManuflexManuflex
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KirschnerKirschner--EhmerEhmer systemsystem
•• ElementsElements
•• DisadvantagesDisadvantages
–– no no potentialpotential forfor usingusing smallersmaller//largerlarger pinspins
–– difficultydifficulty toto useuse positivepositive profileprofile pinspins
–– frequentfrequent failurefailure//looseningloosening of of clampsclamps
–– overcomplexovercomplex framesframes toto protectprotect weakweak frameframecomponentscomponents
–– StraightStraight connectingconnecting bar bar makesmakes idealideal pin pin placementplacementdifficultdifficult
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SecurosSecuros systemsystem/ IMEX/ IMEX--SK SK systemsystem
•• ElementsElements
•• AdvantagesAdvantages toto KK--E E systemsystem
–– BetterBetter strengthstrength and and versatilityversatility
–– PositivePositive profileprofile pinspins
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SecurosSecuros systemsystem
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IMEXIMEX--SK SK systemsystem
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IMEXIMEX--SK SK systemsystem
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PMMA/APEFPMMA/APEF
•• ElementsElements
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PMMA/APEFPMMA/APEF
•• AdvantagesAdvantages
–– easeease of of useuse
–– no no preoppreop planningplanning//preassemblypreassembly
–– minimalminimal riskrisk of pin/bar of pin/bar looseningloosening oror failurefailure
–– FREEDOMFREEDOM of of placingplacing pinspins��pin pin locationlocation notnot
subservientsubservient toto connectingconnecting bar bar positionposition
–– EasilyEasily combinedcombined withwith otherother typestypes
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PMMA/APEFPMMA/APEF
•• DisadvantagesDisadvantages
–– SingleSingle useuse
–– PostopPostop adjustmentadjustment notnot easyeasy
–– DynamisingDynamising notnot easyeasy↔↔KK--EE
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ManuflexManuflex
•• ElementsElements
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ClassificationClassification of of framesframes
•• UnilateralUnilateral ((typetype I)I)–– typetype IaIa
–– typetype IbIb
–– typetype I I tietie--inin configconfig (IM pin)(IM pin)
•• BilateralBilateral ((typetype II)II)
•• MultiplanarMultiplanar ((typetype III)III)--exex. a . a unilateralunilateral//typetype IaIa addedadded toto a a bilateralbilateral
•• CircularCircular//IlizarovIlizarov
•• StrengthStrength & & stiffnessstiffness:: typetype IaIa < < typetype IbIb << typetype I I tietie--inin < < typetype II < II < typetype III)III)
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ClassificationClassification of of framesframes
•• UnilateralUnilateral ((typetype I)I)
–– typetype IaIa
–– typetype IbIb
–– typetype I I tietie--inin configconfig (IM pin)(IM pin)
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ClassificationClassification of of framesframes
•• BilateralBilateral ((typetype II)II)
•• MultiplanarMultiplanar ((typetype III)III)
--exex. a . a unilateralunilateral//typetype IaIa addedadded toto a a bilateralbilateral
•• CircularCircular//IlizarovIlizarov
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Pin Pin TypesTypes
•• SmoothSmooth pinspins ((KK--wirewire, , SteinmannSteinmann pinspins))
–– CheapCheap butbut minimalminimal resistanceresistance toto pulloutpullout
–– InsertedInserted inin an an angleangle (70 (70 degreesdegrees))
•• PositivePositive profileprofile threadedthreaded pinspins
–– More More expensiveexpensive
–– IncreasedIncreased pinpin--bonebone interfaceinterface ( ( pinpin--looseningloosening))
–– No No needneed forfor angulationangulation
–– PreservesPreserves corecore diameterdiameter
–– Less Less proneprone toto pin pin breakagebreakage
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Pin Pin TypesTypes
•• NegativeNegative threadedthreaded pinspins
–– BiggerBigger pinpin--bonebone interfaceinterface
–– ProneProne toto pin pin breakagebreakage ((notnot recommendedrecommended))
•• FullFull pinspins
–– BetterBetter strengthstrength & & stabilitystability
–– HarderHarder toto findfind safesafe softsoft tissuetissue „„corridorscorridors””
–– DemandsDemands more more carefulcareful alignmentalignment
•• HalfHalf pinspins
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Pin Pin InsertionInsertion
•• MOST IMPORTANTMOST IMPORTANT: : correctcorrect limblimb alignmentalignment
•• MM--LL alignmentalignment and torsion!!(and torsion!!(valgusvalgus//varusvarus, ,
abnormalabnormal stressesstresses onon adjacentadjacent jointsjoints))
•• SomeSome CRANCRAN--CAUDCAUD malalignmentmalalignment cancan be be
toleratedtolerated ((elbowelbow//carpuscarpus,,stiflestifle//tarsustarsus cancan
accomodateaccomodate))
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Pin Pin InsertionInsertion
•• ReleasingReleasing softsoft tissuestissues ((preventprevent windupwindup))
•• PrePre--drillingdrilling pin pin holesholes((decreasedecrease heatheat necrosisnecrosis))
•• PinsPins shouldshould be min 0,5be min 0,5--1 cm 1 cm fromfrom jointjoint surfacesurface
and min 2 cm and min 2 cm fromfrom fracturefracture lineline ((fissuresfissures!)!)
•• TwoTwo corticescortices engagedengaged
•• Begin Begin withwith proxprox//distdist onesones��alignmentalignment
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Pin Pin InsertionInsertion
--controllingcontrolling heatheat--
•• AdverseAdverse reactionsreactions:: local local thermalthermal boneboneinjuryinjury++excessiveexcessive locallocal stressstress
•• PinPin--bonebone interfaceinterfaceaffectedaffected��necrosisnecrosis��fibrousfibrous connectiveconnectivetissuetissue��micromovementmicromovement of pinof pin��boneboneresorptionresorption��pinpin--looseningloosening
•• TrocarTrocar pointspoints of of pinspins dontdont facilitatefacilitate egressegress ofofbonebone shardsshards��impactionimpaction��HEATHEAT
•• >50rpm>50rpm�� thermalthermal necrosisnecrosis minimizedminimized
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Pin Pin InsertionInsertion
•• LargerLarger pinspins �� greatergreater pinpin--bonebone interfaceinterface ((dondon’’ttexceedexceed 30%)30%)
•• MoreMore pinspins �� increaseincrease strengthstrength ((maxmax 33--4 per 4 per segmentsegment))
•• StifferStiffer pinspins �� more more eveneven loadload sharingsharing
•• SofterSofter pinspins �� exertsexerts more more stressstress onon nearnear cortexcortex��stressstress��resorptionresorption
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Pin Pin InsertionInsertion SummarySummary
•• AtAt leastleast 3 3 pinspins per per fragmentfragment
•• NearNear/far/far fromfrom fracturefracture sitesite
•• LargestLargest possiblepossible pinspins ((dontdont exceedexceed 30%)30%)
•• StiffStiff pinspins
•• PositivePositive profileprofile threadedthreaded pinspins
•• IfIf usingusing smoothsmooth pinspins 70 70 degreesdegrees!!
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BoneBone healinghealing
•• FactorsFactors affectingaffecting bonebone healinghealing
–– AgeAge & & generalgeneral healthhealth
–– LocationLocation & & typetype of of fracturefracture
–– SurroundingSurrounding softsoft tissuetissue damagedamage
–– ObtainedObtained degreedegree of of fragmentfragment appositionapposition
–– MechanicalMechanical environmentenvironment providedprovided byby ESFESF
•• PrimaryPrimary bonybony unionunion
–– RigidRigid internalinternal fixationfixation + + closeclose contactcontact of of fragmentsfragments
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BoneBone healinghealing
•• SecondarySecondary bonebone healinghealing
–– FractureFracture gapsgaps + + somesome interfragmentaryinterfragmentary
motionmotion
–– ESF is ESF is goodgood exampleexample asas interfragmentayinterfragmentay
comprcompr. . usuallyusually isis notnot appliedapplied (ESF (ESF preservespreserves
bloodblood supplysupply, , importantimportant forfor 2ndary 2ndary unionunion))
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PrimaryPrimary and and secondarysecondary bonybony
unionunion
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BoneBone healinghealing
TRAUMATRAUMA
Soft tissue and bonedamage
HEMATOME
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BoneBone healinghealing
HEMATOME
FIBRIN STABILIZATION
CYTOKINES
MESENCHYMAL CELL PROLIFERATION
VASCULARISATION
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DifferentiationDifferentiation of of mesenchymalmesenchymal
cellscellsSmall amount of interfragmentary strain
And high O2 environment
Osteoblasts
More strain
And lower O2 environmentChondroblasts
Large amount of strain
And low O2 environment
Fibroblasts
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CallusCallus FormationFormation
•• OutsideOutside of of calluscallus has has bestbest mechanicalmechanical & & biologicalbiological environmentenvironment
–– most most resistantresistant toto bendingbending forcesforces (less (less strainstrain))
–– periostealperiosteal bloodblood supplysupply maintainsmaintains highhigh O2 O2 environmentenvironment
•• FractureFracture endsends underunder highhigh strainstrain + + lowlow O2 O2 tensiontension (more (more chondrochondro//fibroblastsfibroblasts))
•• OuterOuter edgeedge of of calluscallus givesgives most most infoinfo ononsecondarysecondary calluscallus formationformation!!
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CallusCallus FormationFormation
•• Limited Limited amountamount of of strainstrain helpshelps bonybony unionunion
((maxmax 2% of 2% of fracturefracture areaarea))
•• ExcessExcess strainstrain leadsleads toto chondrochondro//fibroblastfibroblast
formationformation + + lowlow O2 O2 envenv ��NONUNION!NONUNION!
•• AxialAxial forcesforces promotepromote ����bendingbending//twistingtwisting
forcesforces hinderhinder bonybony unionunion
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PostopPostop XrayXray
•• AAAA=AAAA=alignmentalignment, , appositionapposition, , apparatusapparatus, , activityactivity
•• AreAre therethere adequateadequate numbernumber of of pinspins//segmentssegments??
•• Pin Pin sizesize correctcorrect??
•• AreAre pinspins properlyproperly centeredcentered, , safesafe distancedistance awayawayfromfrom skinskin//fracturefracture lineslines??
•• DoesDoes frameframe configconfig matchmatch fracturefracture typetype//patientpatientsizesize??
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PostopPostop XrayXray
•• AmountAmount of of externalexternal calluscallus is is inverselyinversely
proportionalproportional toto thethe rigidityrigidity of of thethe frameframe
•• OsteomyelitisOsteomyelitis:: roughrough//irregularirregular calluscallus marginsmargins
•• PinPin--looseningloosening:: 1mm 1mm radiolucentradiolucent areaarea aroundaround
pinpin
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PostopPostop XrayXray
•• ResorptionResorption//lacklack of of bridgingbridging calluscallus indicatesindicates
delayeddelayed//nonnon--unionunion
��reexplorationreexploration��bonebone graftinggrafting��newnew fixationfixation
•• GeneralizedGeneralized lossloss of of bonebone densitydensity indicatesindicates stressstress
protectionprotection��stagedstaged dynamizationdynamization
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PostopPostop XrayXray
•• IdeallyIdeally fracturesfractures fillfill upup withwith bonebone densitydensity
materialmaterial afterafter 66--8 8 weeksweeks
•• RechecksRechecks atat 77--10 10 daysdays, 6, 6--8 8 weeksweeks thenthen everyevery 33--4 4
weeksweeks
•• 77--10 10 daysdays recheckrecheck
–– PartiallyPartially weightweight bearingbearing
–– SomeSome edemaedema
–– MildMild painpain onon pin sitepin site
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PostopPostop XrayXray
•• 66--8 8 weeksweeks recheckrecheck
–– UsuallyUsually healedhealed byby thisthis timetime
–– WeightWeight bearingbearing
–– PainPain free pin free pin sitessites ((otherwiseotherwise looseningloosening))
–– XraysXrays ((evaluateevaluate AAAAsAAAAs))�� decisiondecision�� more more timetime, ,
removalremoval, , interventionintervention oror dynamizationdynamization
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ESF ESF cancan be be removedremoved
•• AnimalAnimal is is weightweight bearingbearing
•• SufficientSufficient bonybony calluscallus bridgingbridging thethe fracturefracture gapgap
((densitydensity�� adjacentadjacent bonebone))
•• IfIf severesevere lamenesslameness butbut goodgood calluscallus�� findfind reasonreason
((oftenoften looseloose pin!)pin!)
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More More timetime neededneeded
•• WeightWeight bearingbearing butbut calluscallus notnot completelycompletely
bridgedbridged
•• BridgingBridging calluscallus of of insufficientinsufficient radiodensityradiodensity ((tootoo
stiffstiff frameframe?)?)
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ComplicationsComplications
•• SoftSoft tissuetissue impalementimpalement:: musclesmuscles, , nervesnerves ((cancan
be be severesevere, , „„windwind--upup””) ) tendonstendons, , vesselsvessels
•• ESF ESF faliurefaliure:: frameframe faliurefaliure, pin , pin breakagebreakage, , pinpin
looseningloosening
•• InfectionInfection:: osteomyelitisosteomyelitis, , sequestrationsequestration, ,
major/minor pin major/minor pin tracttract infectionsinfections
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Pin Pin breakagebreakage and and looseningloosening
•• Pin Pin breakagebreakage:: negativenegative threadedthreaded pinpin?, ?, reassessreassess
frameframe strengthstrength//rigidityrigidity
•• Pin Pin pulloutpullout:: smoothsmooth pinspins insertedinserted parallelparallel
•• PramaturePramature pin pin looseningloosening:: veryvery commoncommon
complicationcomplication, , oftenoften poorpoor placementplacement!!
–– IfIf goodgood bonebone unionunion processprocess�� removeremove looseloose pin(s) = pin(s) =
dynamizationdynamization
–– IfIf frameframe is is notnot stabilestabile anymoreanymore�� reviewreview ESFESF
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Pin loosening
Pin tract drainage
Infection
Instability
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OsteomyelitisOsteomyelitis and and sequestrumsequestrum
•• ESF is a ESF is a veryvery effectiveeffective methodmethod toto managemanage
ongoingongoing osteomyelitisosteomyelitis comingcoming fromfrom otherother typetype
of of fixationfixation methodmethod ((internalinternal!)!)
•• SequestrumSequestrum�� resultresult of of thermalthermal necrosisnecrosis ((poorpoor
techniquetechnique, , calcaneuscalcaneus!)!)
–– RemoveRemove pin and drill out pin and drill out tracttract, , draindrain freelyfreely
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Major pin Major pin tracttract infectioninfection
•• CommonCommon complcompl. . causescauses prematurepremature pin pin
looseningloosening
•• BacterialBacterial colonizationcolonization of of pinpin--skinskin interfaceinterface
•• PainPain
•• PurulentPurulent dischargedischarge
•• Pin Pin looseningloosening
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Minor pin Minor pin tracttract infectioninfection
•• ToTo somesome degreedegree itsits normalnormal ((wherewhere thickthick softsoft
tissuetissue))
•• BacterialBacterial contaminationcontamination of of thethe pinpin--skinskin surfacesurface
•• Limited Limited granulationgranulation tissuetissue formationformation
•• LightLight serousserous dischargedischarge
•• LackLack of of painpain
•• No pin No pin looseningloosening
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ThankThank YouYou!!
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