Davos Courses

Executive Editor: Ernst Raaymakers, Joseph Schatzker, Rick Buckley

Authors: Matthias Hansen, Rodrigo Pesantez

Proximal tibia Complete articular fracture, simple articular, multifragmentary metaphyseal - Bridging external fixator

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Glossary

Aftercare following joint-bridging external fixation

Compartment syndrome and nerve injury

Close monitoring of the tibial compartments should be carried out especially during the first 48 hours to rule out compartment syndrome.

The neurovascular status of the extremity must be carefully monitored. Impaired blood supply or developing neurological loss must be investigated as an emergency and dealt with expediently.

Pin-site care

Proper pin insertion
To prevent postoperative complications, pin-insertion technique is more important than any pin-care protocol:

  • Correct placement of pins (see safe zones) avoiding ligaments and tendons, eg tibia anterior
  • Correct insertion of pins (eg trajectory, depth) avoiding heat necrosis
  • Extending skin incisions to release soft-tissue tension around the pin insertion (see inspection and treatment of skin incisions)

Pin-site care
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:

  • The aftercare should follow the same protocol until removal of the external fixator.
  • The pin-insertion sites should be kept clean. Any crusts or exudates should be removed. The pins may be cleaned with saline and/or disinfectant solution/alcohol. The frequency of cleaning depends on the circumstances and varies from daily to weekly but should be done in moderation.
  • No ointments or antibiotic solutions are recommended for routine pin-site care.
  • Dressings are not usually necessary once wound drainage has ceased.
  • Pin-insertion sites need not be protected for showering or bathing with clean water.
  • The patient or the carer should learn and apply the cleaning routine.

Pin loosening or pin tract infection
In case of pin loosening or pin tract infection, the following steps need to be taken:

  • Remove all involved pins and place new pins in a healthy location.
  • Debride the pin sites in the operating theater, using curettage and irrigation.
  • Take specimens for a microbiological study to guide appropriate antibiotic treatment if necessary.

Before changing to a definitive internal fixation an infected pin tract needs to heal. Otherwise infection will result.

Mobilization

In order to avoid severe knee stiffness it is important to restart knee movement as soon as possible. If a joint spanning fixator has been applied because of intraarticular fractures these should be reduced and stabilized within the first few days after the injury if possible.

Depending on the fracture pattern and soft-tissue injuries, it may be preferable to perform a limited fixation of the articular fragments and convert the external fixator to a non-spanning configuration (see modular external fixation with large pins for extraarticular metaphyseal fractures).

Weight bearing

Weight bearing is not allowed.

Follow up

See patient 7-10 days after surgery for a wound check. X-rays are taken to check the reduction.

v2.0 2010-05-15