Throughout this treatment option illustrations of generic fracture patterns are shown, as four different types:
A) Unreduced fracture
B) Reduced fracture
C) Fracture reduced and fixed provisionally
D) Fracture fixed definitively
The modular external fixator is optimal for temporary use. It is rapidly applied without need for intraoperative x-rays and can be adjusted later.
Details of external fixation are described in the basic technique for application of modular external fixator.
Specific considerations for the tibial shaft are given below.
AO teaching video: Modular external fixator
For safe pin placement make use of the safe zones and be familiar with the anatomy of the lower leg.
The pin in the distal tibia should be placed far away from the extensor tendons on the medial side.
Drilling a hole in the thick tibial crest may be associated with excessive heat generation and there is a risk the drill bit may slip medially or laterally damaging the soft tissues. As the anteromedial tibial wall provides adequate thickness for the placement of pins, this trajectory is preferable. A trajectory angle (relative to the sagittal plane) of 20-60° for the proximal fragment and of 30-90° for the distal fragment is recommended.
Alternatively, in order to avoid the frame catching on the opposite leg, the pins may be placed more anteriorly. The drill bit is started with the tip just medial to the anterior crest, and with the drill bit perpendicular to the anteromedial surface (A). As the drill bit starts to penetrate the surface, the drill is gradually moved more anteriorly until the drill bit is in the desired plane (B). This should prevent the tip from sliding down the medial or lateral surface.
Restore length with a bolster behind the knee to give slight flexion.
In order to add further stability to the reduction, a fractured fibula may be plated.
In patients with severe soft-tissue involvement, it may be helpful to add a pin in the foot (one of the tarsal or metatarsal bones) to maintain the ankle at a 90° angle and prevent a plantar flexion contracture.
The pin may be inserted in either the navicular bone, in one of the cuneiforms, in the first metatarsal base, or in the first and fifth metatarsal base, and connected with a rod to the tibial external fixator. Care should be taken to insert the pin bicortically and to avoid the intra-articular spaces.
Proper pin insertion
To prevent postoperative complications, pin-insertion technique is more important than any pin-care protocol:
Various aftercare protocols to prevent pin tract infection have been established by experts worldwide. Therefore no standard protocol for pin-site care can be stated here. Nevertheless, the following points are recommended:
Pin loosening or pin tract infection
In case of pin/wire loosening or pin tract infection, the following steps need to be taken:
Before changing to a definitive internal fixation an infected pin tract needs to heal. Otherwise infection will result.
Unless there are other injuries or complications, mobilization may be performed on day 1. Static quadriceps exercises with passive range of motion of the knee should be encouraged. Early active range of motion of knee and ankle is encouraged.
The goal of early active and passive range of motion is to achieve a full range of motion within the first 4-6 weeks. Maximum stability is achieved at the time of surgery. A delay beyond a few days to allow swelling to subside is illogical and harmful.
If external fixation is considered as the definitive device, weight bearing should be encouraged early. The timing and how much weight may be taken through the fracture will be influenced by:
As soon as callus formation is visible and once there are no clinical signs of instability, the patient can start to bear full weight. After removal of the external fixator, it may be prudent to protect the leg temporarily in a splint or brace.
See patient 7-10 days after surgery for a wound check. X-rays are taken to check the reduction.
The patient should be seen every 4-6 weeks in follow-up with examination and x-rays until union is secure, and range of motion and strength have returned.
Inspection of external fixators every two weeks is optional.