- External Fixation Main Menu:
- Discussion:
- disadvantages of external fixation:
- pin tract infections, delayed union /
non-union, and
malunion;
- cosmetic problems;
- advantages of external fixation:
- technically easy to perform;
- no soft tissue stripping;
- ease of removing hardware;
-
comparison of IM nailing vs external fixation:
- Initial Considerations:
-
compartment syndrome:
- w/ a difficult fracture reduction, consider making the
fasciotomy incision slightly closer to the tibia
so that the fracture site can be palpated and bone holding clamps can be applied;
-
vascular injuries associated w/ tibial frx;
- provisional external fixation should be applied first so that manipulation of the frx will not disrupt the anatomosis;
- ensure that the proposed frame will not interfere w/ subsequent revascularization procedures;
-
open fractures:
-
debridment:
- aggressive & repeated debridments of all devitalized tissue, including bone fragments;
- soft tissue lacerations should be temporarily closed w/ towel clips prior to application of
the fixator so that the wound edges are not gaped open by the half pins;
- likewise,
fasciotomy incision should be temporarily closed w/ towel clips towel clips
so that the fixator pins do not cause the wound to gape open;
-
soft tissue coverage for the leg
- ensure that the proposed frame will not interfere w/ subsequent reconstructive procedures;
- references:
-
The role of supplemental lag-screw fixation for open fractures of the tibial shaft treated with external fixation.
-
Open tibial fractures treated by anterior half-pin frame fixation.
-
Severe open tibial fractures. Results treating 202 injuries with external fixation.
-
Plates versus external fixation in severe open tibial shaft fractures. A randomized trial.
-
The management of open tibial fractures with associated soft-tissue loss: external pin fixation with early flap coverage.
-
Complicated open fractures of the distal tibia treated by secondary interlocking nailing.
- Operative Considerations:
-
enhancement of fixator stability;
-
safe zone of pin insertion:
-
foot inclusion: may be indicated for
open fractures and distal fractures;
-
choice of hardware:
- uniplanar fixators:
-
Synthes:
-
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;
-
reduction:
- usually should be carried out prior to fixator application;
-
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 the saggital plane improves stability;
-
comminuted fractures: (or oblique frx)
- if frx is comminuted or oblique fracture fragments will not transmit axial load;
- these frx require stacked frame for enhanced stability;
- see:
enhancement of fixator stability;
-
diaphyeal fractures:
- appropriate length is fitted with 4 pin holding clamps;
- place most proximal & distal holding clamps as far apart as possible
- proximal pin is placed, preferably at junction of diaphysis and metaphysis, to gain purchase in the thick cortical bone;
- place inner holding clamps approx 2 cm from frx site;
-
proximal frx:
- see:
-
tibial plateau frx
-
considerations for IM nailing of proximal tibial frx;
- small proximal tibal fragment can be stabilized w/ external fixator using a cluster of 2-3 transfixation pins from
lateral to medial, alternatively a hybrid
circular wire fixator may be required;
- generally, the first half pin is inserted into shorter fragment;
- half pins should be placed at least 1-2 cm from the joint line in order to avoid possible septic arthritis (this
may be especially important in diabetics);
- if a cancellous site is chosen, the hole is drilled only with the 3.5 mm drill, and a 5.0 mm Schanz screw is used;
- references:
Safe extracapsular placement of proximal tibia transfixation pins.
-
external fixation for distal tibia frx: (see
pilon fracture)
- Post Operative Care and Complications:
-
bone grafting for tibial fracture:
-
exchange IM nailing:
-
non-union
-
prognosis for healing;
The Role of Supplemental Lag-Screw Fixation for Open Fractures of the Tibial Shaft Treated With External Fixation.
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.
RhBMP-7 accelerates the healing in distal tibial fractures treated by external fixation.
