Navigating the Zone of Injury: A Scoping Review of Outcomes Surrounding External Fixator Pin Placement in Open Fractures.

Abstract

The anatomical placement of external fixator pins is considered critical in the management of open fractures, particularly with respect to avoiding compromised soft tissue. Although conventional surgical practices advise placing pins outside the zone of injury, this practice is based on expert opinion rather than peer-reviewed evidence. This gap poses potential adverse patient outcomes and warrants thorough clinical investigation. This scoping review aims to map the available literature on external fixator pin placement in relation to the wound zone of open fractures and identify any associated complications whilst examining current surgical guidance on this issue. A scoping review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines. Four databases (PubMed, EMBASE, Ovid MEDLINE, and Google Scholar) were searched, alongside grey literature sources such as the Arbeitsgemeinschaft für Osteosynthesefragen (AO) Surgery Reference and Orthopaedic Trauma Association (OTA) guidelines. Eligible sources included those addressing pin placement in open fractures, particularly in or near soft tissue wounds. Of the 241 records screened, no peer-reviewed studies directly examined pin placement within or near the wound zone. A small number of studies discussed pin-plate overlap, with mixed findings on infection risk. Expert guidance from surgical references consistently recommends avoiding compromised soft tissue, but this is not supported by empirical evidence. No clinical studies directly evaluate the outcomes of external fixator pin placement within open fracture wounds or compromised tissues. Existing guidance is largely based on expert consensus. Further research is needed to determine whether such placement impacts infection risk or clinical outcomes.