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Ultrasound-assisted external fixation: a technique for austere environments
  1. Max Talbot1,
  2. E J Harvey2,
  3. R Reindl2,
  4. P Martineau2 and
  5. P Schneider2
  1. 1Canadian Armed Forces, Royal Canadian Medical Service, Montréal, Canada
  2. 2Department of Surgery, McGill University, Montréal, Canada
  1. Correspondence to LCol Max Talbot, Canadian Armed Forces, Royal Canadian Medical Service, BB104, PO Box 9999, Stn Main, Petawawa, ON K8H 2X3


Introduction Ultrasound-assisted external fixation of long bones has the potential to enhance extremity damage control surgery in locations without fluoroscopy, such as forward surgical elements, the intensive care unit, and spacecraft. This pre-clinical study specifically sought to evaluate orthopaedic surgeons' ability to sonographically define fracture patterns and the associated zone of injury in order to improve surgical decision-making and safely insert Schanz pin percutaneously.

Methods We encased small composite femurs in a cylindrical echogenic gelatin matrix to simulate a human thigh. Three orthopaedic trauma surgeons with no prior ultrasound experience were taught to use sonography to diagnose fractures and assist external fixation. The surgeons were then presented with five specimens in a randomized sequence: three diaphyseal fractures (32-A2, 32-C2 and 32-C3); a distal femur fracture (33-A1.2); and an intact femur, all encased in an opaque black gelatin matrix to blind the participants to the underlying pathology. If they diagnosed a diaphyseal fracture, the surgeons were instructed to insert two Schanz pins proximal and two distal to the fracture, no closer than 40 mm from the fracture edges.

Results Fracture diagnosis and surgical decision-making were correct in all cases. All intact femurs were recognized as such. The need for a knee-spanning external fixator was recognized for all distal femur fractures. The three surgeons performed appropriate ultrasound-assisted pin placement in every case of diaphyseal fracture. The pins adjacent to the fracture site were on average 58 mm (SD ±11 mm) from the edge of the fracture. No pins were inserted in the fracture or in the knee joint.

Conclusions The current study results suggest that with minimal training, orthopaedic surgeons can use portable ultrasound to diagnose femur fractures, decide the appropriate external fixator configuration, and safely insert Schanz pins outside the zone of injury.


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  • Contributors All authors contributed to the planning, conduct and reporting of the research.

  • Funding This study, including implants and composite bones, was funded directly by the first author without commercial or grant support.

  • Competing interests Unrelated to the current paper, some of the authors have peer reviewed grants or pending grants from the Canadian Institutes of Health Research, Lymphoma Canada, the Orthopaedic Trauma Association, the Natural Sciences and Engineering Research Council of Canada and an institutional educational grant from Depuy-Synthes. Some of the authors are members of the editorial board of the Canadian Journal of Surgery.

  • Provenance and peer review Not commissioned; externally peer reviewed.