External Fixators for Distal Tibial Frx     

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- See: IM Nailing for Distal Tibia Fracture:

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- Discussion:
    - reduction:
            - usually should be carried out prior to fixator application; 
            - care is taken to ensure proper tibial rotation (center of patell to tibial tubercle creates a line to the 2nd toe)
    - plate fixation of fibula:
            - The role of fibular fixation in combined fractures of the tibia and fibula: a biomechanical investigation.
            - Plating of the fibula. Its potential value as an adjunct to external fixation of the tibia.
            - The effect of concurrent fibular fracture on the fixation of distal tibia fractures: a laboratory comparison of intramedullary nails with locked plates.
            - Role of the fibula in distal tibial fracture
    - plane of the fixator:
            - consider the need for soft tissue coverage and position the fixator in way that not to interfere with free flap coverage;
            - because major bending moments on tibia during gait are in saggital plane, placment of fixator pins and frame near saggital plane improves stability; 

    - safe zone of pin insertion: 
             - need to avoid muscle impalement:
             - avoid impaling anterior tibial or toe extensor tendons;
             - w/ external fixators about the ankle, there is greater incidence of drainage from transfixtion that passed thru middle of anterior compartment than from half pins
                       placed thru medial tibia which underlies rather stationary subQ tissues;
             - references:
                     - Extracapsular Placement of Distal Tibial Transfixation Wires.
                     - Soft tissue injuries with the use of safe corridors for transfixion wire placement during external fixation of distal tibia fractures: an anatomic study.
                     - Anatomy of the distal knee joint and pyarthrosis following external fixation.
                    - The proximal extent of the ankle capsule and safety for the insertion of percutaneous fine wires. 

    - enhancement of fixator stability; 
    - foot inclusion: may be indicated for open fractures and distal fractures;
    - choice of hardware:
            - uniplanar fixators: Synthes: and Orthofix fixator;
            - circular wire fixators:  Ilizarov Menu: Synthes Hybrid Fixator  Orthofix Hybrid System; 
    - dynamization:
            - alawys consider the need for postoperative dynamization, hence plan the configuration to allow for shortening;
            - this is especially important for the orthofix fixator since postoperative shortening will not be possible unless the fixator is initially lengthened; 
            - references:
                   - Dynamization timing and its effect on bone healing when using the Orthofix Dynamic Axial Fixator.


                   

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Plates versus external fixation in severe open tibial shaft fractures. A randomized trial.

Tibial external fixation, weight bearing, and fracture movement.

Analysis of the external fixator pin-bone interface.

Cortical Bone Reactions at the Interface of External Fixation Half-Pins Under Different Loading Conditions.

The role of external fixation in the treatment of posttraumatic osteomyelitis.

Treatment of Type II, IIIa, and IIIb open fractures of the tibial shaft: A prospective comparision of unreamed interlocking intramedullary nails and half pin external fixators.
     MB Henley et al.  J. Orthopaedic Trauma.  Vol 12. No 1. Jan 1998. p 1-7

Severe open tibial fractures. Results treating 202 injuries with external fixation.

Mechanical Influences on Tibial Fracture Healing.

Treatment of Distal Tibia Fractures Without Articular Involvement: A Systematic Review of 1125 Fractures.

Treatment of Distal Tibia Fractures Without Articular Involvement: A Systematic Review of 1125 Fractures.

Two-ring hybrid external fixation of distal tibial fractures: a review of 47 cases.

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