OT notes · Orthopaedics

Application of external fixator

Usual anaesthesia
Spinal (subarachnoid block); general anaesthesia in polytrauma
Position
Supine, injured leg raised on a bump or sandbag under the ipsilateral hip, heel on a sterile bump
Setting
emergency

Operative note template for application of a monolateral (half-pin) external fixator, mainly for the tibia, with a filled example for a temporary four-pin frame on an open tibial shaft fracture after debridement.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • pin-site infection, pin loosening
  • nerve or vessel injury from a pin
  • loss of reduction, malunion
  • delayed union or non-union
  • need for further surgery: debridement, flap, conversion to nail or plate
  • fracture through a pin hole
  • joint stiffness, equinus contracture of the ankle
  • compartment syndrome

Pre-operative details for this operation

  1. IndicationOpen fracture with severe soft tissue injury / contaminationClosed fracture with high-grade soft tissue injuryTemporary spanning for plateau / pilon fracturePolytrauma: damage controlDefinitive fixation
  2. Bone, side, fracture levelshaft / metaphysis / extension into knee or ankle; open fracture grade; wound size and site
  3. Distal neurovascular statusdorsalis pedis and posterior tibial pulses at the ankle, capillary refill, sensation, toe movement
  4. CompartmentsSoftTense: pressure measured / fasciotomy planned
  5. Planned future incisions markedso pins stay out of the zone of injury and out of future plate incisions
  6. Tetanus prophylaxis (open fracture)given / status

Anaesthesia and position

  1. AnaesthesiaSpinalGeneral
  2. PositionSupine, bump under ipsilateral hip, heel on sterile bump
  3. TourniquetNot usedUsedif used: pressure and time
  4. C-armplaced on the side opposite the injured leg

Operative findings

  1. Wound and soft tissuesize, contamination, muscle viability, bone exposed (if debridement done, see separate note)
  2. Fracture patternlevel, comminution, bone loss
  3. Alignment after reduction on C-armlength, angulation, rotation compared with other limb

Procedure (steps)

  1. Parts painted and drapedwhole limb free
  2. Frame typeSimple monolateral (pin-bar clamps and rods)MonotubeKnee-spanningAnkle-spanning with calcaneal pinTwo-pin travelling tractionCircular / hybrid
  3. Pin insertion techniquestab incision at pin site, blunt dissection to bone, trocar and drill sleeve, predrilled with saline cooling, pin inserted by hand / power, bicortical, not transcortical
  4. Pin sitessurface (anteromedial / subcutaneous border of tibia, anterolateral femur, calcaneus, 1st metatarsal), distance from fracture and wound
  5. Pinsnumber above and below fracture, diameter (not more than one-third of bone diameter), length, self-drilling or not
  6. ReductionOuter pins first, rod, traction, then inner pinsTwo pin groups, each with a rod, reduced then linked with a third rodMonotube: ball joints and body locked after reduction
  7. Rods and clampsnumber and length of rods, single or double stack, number of pin-bar and bar-bar clamps, bone-to-rod distance
  8. Clamps tightened, C-arm checkAP and lateral of whole bone and adjacent joints; number of images saved
  9. Skin release around pinstethered skin released with scalpel
  10. Foot position (tibia / ankle frames)Not spannedMetatarsal pin to hold foot neutralSplint to prevent equinus

Closure, drains and dressing

  1. Wound (open fracture)Left open, dressedClosed primarilyNegative pressure dressing
  2. Pin-site dressinggauze wrapped around each pin, compressive
  3. Distal neurovascular status and compartments at end

Specimens and implants

  1. Pinsnumber, diameter, length, type; make, lot/batch, sticker
  2. Frame componentsrods (number, length), clamps (number, type); make; lot/batch if labelled
  3. Tissue sentNoneWound swab / tissue cultureDebrided tissue for HPE
  4. C-arm images saved

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. Limb elevationon pillows, above heart level
  2. Neurovascular and compartment watchpulses, capillary refill, toe movement, pain on passive stretch
  3. Pin-site carecompressive gauze wrap; state method and frequency; no ointments
  4. Wound care (open fracture)dressing plan, date of planned re-look or cover
  5. Antibiotics (open fracture)drug, dose, duration as per open-fracture protocol
  6. Weight bearingnon-weight bearing / as allowed; state
  7. Ankle positionsplint or metatarsal pin to keep foot neutral
  8. Check X-rayAP and lateral of whole bone in frame
  9. Plandefinitive fixation / conversion to nail or plate when soft tissue allows

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Mr. D.S., 28 years, motorcycle accident. Open fracture of the middle third of the right tibia and fibula with a 6 cm contaminated wound over the anteromedial leg (Gustilo IIIA). Wound debridement done first under the same anaesthesia (separate note). Temporary monolateral fixator applied.

Case details

Date: 11/09/2026. Emergency list. OT 3.

In OT 23:10. Spinal 23:18. Debridement 23:30 to 00:05. Frame application 00:10 to 00:55.

Surgeon: Dr A. (3rd-year resident, Orthopaedics). Assistant: Dr B. Consultant: Dr C., informed, available.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Open fracture right tibia and fibula, middle third, Gustilo IIIA, soil contamination. Temporary stabilisation for wound care; nailing planned later.

Pre-op: dorsalis pedis and posterior tibial pulses palpable, capillary refill under 2 s, sensation over dorsum and sole normal, toes moving. Compartments soft.

Tetanus toxoid given in casualty. IV antibiotics started in casualty as per open-fracture protocol.

Consent taken in Hindi, including further surgeries. Site marked. WHO checklist done.

Anaesthesia and position

Spinal anaesthesia. Supine, bump under right hip, heel on sterile bump. No tourniquet.

C-arm on the left side. Whole right leg painted with povidone-iodine and draped free.

Procedure

After debridement (see separate note), fracture: transverse with small butterfly, middle third tibia, no bone loss.

Frame: simple monolateral, anteromedial. Pin sites chosen away from the wound and from the proximal and distal nail entry areas.

At each pin site: 1 cm stab incision, blunt dissection to bone, trocar and drill sleeve to bone, predrilled at low speed with saline cooling, 5 mm Schanz pin inserted by hand with T-handle, bicortical. Central canal position checked on C-arm.

First pin in proximal tibia and first pin in distal tibia, each far from the fracture. One rod attached close to bone. Longitudinal traction and manipulation gave gross reduction.

Two inner pins placed near the fracture on either side, using the clamps on the rod as templates, outside the zone of injury.

Reduction fine-tuned. Second rod added (double stack). All clamps tightened.

C-arm AP and lateral of whole tibia, knee and ankle: length and alignment restored, no rotation compared with left leg, all pins bicortical. 4 images saved.

Skin around two pins was tethered and released with a scalpel.

Foot held in neutral with a below-knee posterior slab.

Closure

Wound left open after debridement, dressed with saline gauze.

Each pin site wrapped with gauze and compressed.

At end: dorsalis pedis and posterior tibial pulses palpable, toes pink, compartments soft.

Specimens and implants

Deep tissue sent for culture (see debridement note).

Implants: 4 Schanz pins 5 mm x 150 mm stainless steel; 2 rods 11 mm x 300 mm (double stack); 8 pin-rod clamps (4 on each rod). Make and lot/batch no. as on packets; stickers pasted in case sheet and implant register.

C-arm: 4 images saved.

End of procedure

Estimated blood loss 150 ml (mostly during debridement). Mop, needle and instrument count correct. No intra-operative complications.

Shifted to recovery, stable. Pulse 92/min, BP 118/74 mmHg.

Post-op orders

Right leg elevated on pillows. Toe movement, capillary refill, pulses and pain on passive toe stretch hourly for 24 h.

IV antibiotics as per open-fracture protocol. Analgesia as per anaesthesia chart.

Pin sites: keep compressive gauze wrap; no ointment. Wound inspection and re-look debridement plan by consultant.

Non-weight bearing right leg. Check X-ray right leg AP and lateral in frame.

Plan: conversion to intramedullary nail when wound allows.

Signature

Dr A., JR-3, Orthopaedics. Reg. no. ________. 12/09/2026, 01:10.

Must document for this operation

  • Pin positions relative to the wound and to future incisions or nail entry. The surgeon doing definitive fixation needs to know whether pin tracts overlap the planned implant, which raises infection risk.
  • Pin details: number, diameter, length, bicortical placement, and frame parts used, with lot/batch and stickers. Needed for audit of pin problems, for frame adjustment, and for implant traceability.
  • Distal neurovascular status and compartments before and after. High-energy tibial injuries carry a risk of vascular injury and compartment syndrome; the record shows it was checked.
  • Frame type, whether temporary or definitive, and the plan for conversion. Delay in converting a temporary frame is a known risk factor for infection; the plan must be clear to the next team.
  • Alignment achieved on C-arm and images saved. Malunion is more common after external fixation; the saved images show the alignment at the end of surgery.
  • Wound status and what was done to it. Open-fracture outcome depends on wound management and timing of cover, which are audited.

Common mistakes in these notes

  • Writing 'ex-fix applied' with no frame type, number of pins or pin size.
  • Not saying whether the frame is temporary or definitive.
  • No pin-site care instruction in post-op orders.
  • Leaving out the foot position in tibial or ankle-spanning frames.
  • No record of distal pulses before and after.

Indian practice and paperwork

  • Record the batch and serial number of pins and frame parts in the case sheet; NABH also asks for it in the implant logbook and the discharge summary. (NABH Accreditation Standards for Hospitals, 5th ed. (2020), MOM.10(d))

Sources

  • Operative Techniques in Orthopaedic Trauma Surgery. 2nd ed. Wolters Kluwer, Ch 50, External fixation of the tibia (Watson JT), pp. e-book markers P.531-P.546.
  • Campbell's Operative Orthopaedics. 15th ed. Elsevier, Ch 58, General principles of fracture treatment: external fixation, Technique 58.6 and 58.7, pp. 2552-2560.

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

Videos of this operation

Teaching videos and pages for this operation, listed under the curriculum item that asks for it.

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