Intended for healthcare professionals


Current concepts in external fixation in trauma

BMJ 2009; 339 doi: (Published 12 August 2009) Cite this as: BMJ 2009;339:b3091
  1. Stephen P Guy, specialist registrar1,
  2. Peter Loughenbury, specialty trainee 3 2
  1. 1Department of Trauma and Orthopaedics, Bradford Royal Infirmary, Duckworth Lane, Bradford BD9 6RJ
  2. 2Department of Trauma and Orthopaedics, Leeds General Infirmary, Great George Street, Leeds LS1 3EX

What is it?

A one day course on the use of external fixation in trauma. Short interactive lectures and dry bone workshops give trainees a stress free introduction to the use of external fixation and its application in real life scenarios.

Who’s it for?

Trauma and orthopaedic specialty trainees, ideally people in core trainee years 1-2 and specialty trainee years 3-4. The course would also be useful for foundation trainees with an interest in orthopaedics and trauma.

When did you do it?

At the start of specialty training year 3.

Why did you do it?

Working in a tertiary centre as a junior registrar can be daunting, in particular having to definitively manage the polytraumatised patient or patients with complex open or closed high energy fractures. The safe application of external fixators can be both life saving and limb saving provided it is done correctly. A study conducted by one of the trainers showed that external fixators had been incorrectly constructed in the vast majority of patients arriving for tertiary management. In addition, the average trainee will not have performed sufficient external fixation procedures by the time they achieve a certificate of completion of training. In the future the European Working Time Directive will further reduce these figures, so it seems that a course like Current concepts in external fixation in trauma should be deemed compulsory. We did the course, therefore, to plug the experiential gap and be forearmed for any difficult cases in our careers. Given that 85% of my on calls this year included dealing with at least one open fracture, the course has proved invaluable.

How much effort did it entail?

Very little preparation is needed and there is no pre-course material, but some knowledge of the indications for external fixation in trauma is useful. If you wanted to do some pre-course reading then it would be best to look at the surgical techniques of pin insertion in the lower leg and pelvis. Also, awareness of the British Orthopaedic Association/British Association of Plastic Surgeons’ guidelines on the management of open tibial fractures is helpful.

Is there an exam?

There is no formal exam but there are some basic questions at the start and end of the course. You will be asked how you would apply a temporary external fixator to treat different fracture patterns. At the end the same questions are asked and you’ll find that your answers have changed significantly. This approach reinforces your learning objectives and the fact that you probably needed to go on the course. There is no pass mark and you can keep your answers to yourself.

How is the course structured?

Lecture topics include basic anatomy and surgical techniques, basic biomechanics, and the management of open fractures. Workshops give you an opportunity to practise the application of temporary external fixation to lower limb, wrist, and pelvis dry bone specimens. There are also introductory lectures on the use of definitive external fixation and the use of external fixation in children.

All the lectures are clear and well delivered, with opportunity for discourse throughout. The practical sessions are directly related to the lectures and allow you to practise the learning points from each lecture. The course tutors are well published, energetic, knowledgeable, and approachable.

How much does it cost?

£75 in Leeds and £120 in London.

Was it worth it?

Definitely. There is very little chance to learn how to apply external fixation in the early years of training. It is an important skill and one of the first things you can be left to do alone once you take up post at specialist registrar level. This course gives you an opportunity to learn these skills in a controlled environment and get advice from experts in external fixation.

Top tip

Familiarise yourself with the external fixator kit you have in your trust, and read the manual.

Further information

Courses are held at the Royal College of Surgeons in London (orthopaedics{at}; 020 7869 6337) and the Leeds General Infirmary (next course 5 October 2009; jean.fretwell{at}; 0113 3923819).


  • Competing interests: None declared.

View Abstract