External fixation use in the management of massive upper extremity trauma

Immobilization of fractures associated with instability and comminution by an external skeletal device facilitates wound care, skin coverage, and ultimate reconstructive surgery. External skeletal fixation was applied in 20 patients who sustained complex open injuries of the upper extremity. All injuries were associated with extensive soft tissue and skin defects. Associated neurovascular injuries included 14 nerve injuries and five major vascular injuries. The Hoffman fixation device was used in the majority of cases. Skin coverage was obtained in all patients by an appropriate method of skin grafts, pedicle flaps, and a free myocutaneous flap. Primary bone union was achieved in five of 16 patients. Ten of 16 patients required secondary procedure to obtain union in cases of delayed union or nonunion, and one case remained with a nonunion. Pin tract infection in three patients and osteomyelitis in two patients were effectively treated with antibiotics and appropriate surgery. The initial treatment goals of limb salvage, skin coverage, and bone stabilization without drainage or persistent osteomyelitis can be accomplished by the use of external skeletal fixation devices.