Davos Courses

Executive Editor: Ernst Raaymakers, Joseph Schatzker, Rick Buckley

Authors: Matthias Hansen, Rodrigo Pesantez

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

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Glossary

Aftercare following nonbridging 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/wire insertion
To prevent postoperative complications, pin/wire-insertion technique is more important than any pin/wire-care protocol:

  • Correct placement of pins/wires (see safe zones) avoiding ligaments and tendons, eg tibia anterior
  • Correct insertion of pins/wires (eg trajectory, depth) avoiding heat necrosis
  • Extending skin incisions to release soft-tissue tension around the pin/wire 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/wire-insertion sites should be kept clean. Any crusts or exudates should be removed. The pins/wires 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/wire-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/wire loosening or pin tract infection
In case of pin/wire loosening or pin tract infection, the following steps need to be taken:

  • Remove all involved pins/wires and place new pins/wires 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

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.

Weight bearing

Partial weight bearing may be allowed only in extraarticular metaphyseal fractures. Weight bearing is usually avoided in the treatment of articular fractures.

The timing and how much weight may be taken through the fracture will be influenced by:

  • Patient factors
  • Fracture configuration
  • Stability of the fixator construct

Follow up

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

Frequency of outpatient follow-up depends on the complexity of the injury and on the compliance of the patient. The follow-up visits should not be spaced more than three weeks apart.

v2.0 2010-05-15