External Fixation of Lower Extremity Injuries in an Austere Environment: A Technique for Safe Application Without the Use of Fluoroscopy

External fixation is a fundamental technique for the initial care of major extremity trauma. External fixation is used to provide temporary stability in both the damage control setting and environments where resources for definitive fixation are not readily available or definitive fixation is ill-advised. In the austere or resource-constrained environment-particularly in the battlefield setting or in disaster response-external fixation has demonstrated to be a reliable and efficient method for stabilizing the injured extremity without notable disruption of the soft-tissue envelope. Although instruments and implants used for external fixation are highly portable, standard intraoperative fluoroscopy is cumbersome and often unavailable outside of a standard operating room. We present a safe, reproducible technique for external fixator placement without the use of fluoroscopic guidance. In addition to its utility in austere environments, this technique offers several advantages in the standard healthcare setting, particularly in minimizing radiation exposure and allowing for application of an external fixator in settings not optimized for fluoroscopic imaging such as the intensive care unit or combined damage control surgical cases where a nonradiolucent operating room table is used.