Executive Editor: Peter Trafton, Michael Baumgaertner

Authors: Martin Hessmann, Sean Nork, Christoph Sommer, Bruce Twaddle

Distal tibia Complete articular simple fracture, multifragmentary metaphyseal

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1 Principles of hybrid external fixation top

Hybrid external fixation for distal tibia complete articular fractures enlarge

By bridging from the epiphysis to the diaphysis, the fixator stabilizes the metadiaphyseal region.

Intraarticular fractures should be anatomically reduced and held with lag screws or reduction wires.

More complex articular fracture patterns, with fragment displacement, may require a separate open reduction. Interfragmentary fixation, typically with lag screws, should be added in a way that also permits wire placement.

A ring fixator placed distally may be useful to hold complex distal fractures and can be attached to the tibial shaft with pins and rods (hybrid fixation).

Details of external fixation are described in the basic technique for application of modular external fixator.

Specific considerations for hybrid external fixation in the distal tibia are given below.

2 Patient preparation top


This procedure is normally performed with the patient in a supine position.

3 Safe zones for wire and pin placement top


Knowledge of safe zones and anatomy of the lower leg and the foot is essential for safe wire and pin placement.

4 Wire placement top

Planning of wire placement for hybrid external fixation in distal tibia complete articular fractures enlarge

Planning of wire placement

2 mm diameter wires are recommended.

Placement of wires for distal tibial fixation must be carefully planned. The fracture planes must be determined. Wires must support rather than prevent reduction. Provisional reduction and temporary K-wires might be required.

Interfragmentary compression may be achieved using reduction wires perpendicular to the fracture plane.

Alternatively, lag screws may be placed before the fixator.

Note: If opposed reduction wires will be used for fracture compression, their location must be planned regarding both fracture anatomy and local structures.

In addition to distal ring and tensioned wires, the proximal pins and frame, and its connection to the ring, must be planned for maximal stability.

Safe wire placement in the distal tibia enlarge

Safe wire placement in the distal tibia

Many important structures surround the ankle and must not be injured by the wires. Good knowledge of anatomy is mandatory.

No consistently safe zones for pin or wire insertion in the distal tibia have been identified. Use a small incision and spread the tissues to expose bone. Avoid nerves and vessels. If a tendon is impaled, the offending wire must be changed.

To reduce the risk of joint infection, avoid intraarticular placement of the wires, if possible. Pins that are inserted less than 20 mm proximal to the tibiotalar joint may enter the joint capsule.

With only two wires, stability is limited. Maintaining an overall arc of 60-80° between the wires improves stability, but even better is to add a third wire or a threaded pin.

5 Ring placement top

Preliminary reduction

For complete articular fractures, the joint surface must be satisfactorily reduced before a wire is placed across it. This may require open reduction with a small anterior incision, and provisional or definitive fixation.

Insertion of the first wire in the distal tibia for hybrid external fixation enlarge

Insertion of the first wire

Make a stab incision and use blunt dissection down to the bone.

Insert the protection sleeve until it reaches the bone. Place the wire parallel to the tibiotalar joint under image intensification until it penetrates the far cortex. Finish wire insertion by hand, until the wire extends an equal length on both sides of the tibia. Make sure that the wire does not impale tendons or neurovascular structures.

Insertion of a non-olive wire in the distal tibia for hybrid external fixation enlarge

Option for insertion of first wire

A non-olive wire placed through the fibula to emerge from the anteromedial tibia is often a good first wire. It is inserted from posterolateral (avoiding peroneal tendons) to anteromedial, parallel to the ankle joint.

Ring placement for hybrid external fixation enlarge

Attaching ring to first wire

Place a wire-to-ring clamp on either end of the wire and attach these clamps to the ring, keeping the wire straight.

Tighten the clamps to the ring and then provisionally to the wire.

Option: Some surgeons place two wires initially and then attach the ring to both.

Insertion of additional wires in the distal tibia for hybrid external fixation enlarge

Insertion of additional wires

The wire-to-ring clamps may serve as guides for insertion of additional wires. The angle between the first and the second wire should be as wide as possible. Confirm that the articular reduction is satisfactory.

It is advisable to use at least three distal wires, or two with a supplementary threaded pin.

Wire tensioning for hybrid external fixation enlarge

Wire tensioning

Flexible wires must be under tension for mechanical stability. Generally, a tension of 100 kg force is appropriate.

Pearl: While tensioning the second wire, the tension in the first may decrease due to ring deformation. Both wires should be retensioned to obtain better stability. If two tensioning devices are available, they can be used simultaneously to ensure equal tension in the two wires.

Reduction wires for hybrid external fixation enlarge

Pearl: Reduction wires have small beads called “olives”.

Insertion of reduction wires for hybrid external fixation enlarge

Articular fracture fragments may be held with interfragmentary lag screws.

Alternatively, when the fracture configuration is appropriate, this may be achieved using reduction wires (with “olives”), which will be inserted and tensioned as first wires.

Applying reduction wires with olives is demanding and should only be performed by surgeons trained in this technique.

6 Pin insertion (tibial shaft) top

Choice of tibial pin placement for hybrid external fixation enlarge

Choice of tibial pin placement

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.

Alternative tibial pin placement for hybrid external fixation enlarge

Alternatively, 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.

7 Ring-to-rod connection top

An anteromedial rod is placed and attached to the ring to hold the provisional reduction. Then an anterolateral rod and cross brace is added for mechanical stability, with supplementary diaphyseal pins in multiple planes.

Placement of the first rod for hybrid external fixation enlarge

Placement of the first rod

Place an anteromedial proximal pin first. Choose a rod that is long enough to connect the pin to a clamp on the medial side of the ring. Place a rod-to-rod clamp and then a second rod-to-pin clamp on the rod.

Then attach the distal end of the rod to the ring, with a rod-to-ring clamp, with approximate fracture reduction. Angular alignment, length, and rotation must each be restored.

Next, insert a pin in the distal shaft through the rod-to-pin clamp.

8 Reduction and fixation top

Reduction and fixation of a distal tibia fracture with hybrid external fixation enlarge

Loosen the rod-to-ring clamp. Reduce the segments using ring and rod as reduction handles. Restore length, alignment and rotation. Check reduction clinically and with image intensification. If reduction is satisfactory, tighten the ring-to-rod clamp.

9 Frame completion top

Frame completion of hybrid external fixation enlarge

Second and third rod

Attach the anterolateral rod to the proximal pin and to the ring laterally, using a rod-to-ring clamp. A rod-to-rod clamp is first placed on the rod.

Once the anterolateral rod is positioned, and reduction reconfirmed, connect the two rods with a short cross-brace using the previously placed clamps. If reduction remains satisfactory, tighten all frame clamps.

Additional pin fixation in hybrid external fixation enlarge

Additional pin from ring (option)

A pin from the ring may be used for fixation to the distal shaft. This is placed through a ring-to-pin clamp, directed proximally, towards the anteromedial tibial shaft, proximal to the fracture zone. (An alternative supplementary pin must be chosen if comminution extends too far proximally.)

Predrill if necessary for thick cortex. Place the pin, using the previously described technique, and tighten the clamp.

Once again, confirm the reduction. If satisfactory, tighten all the clamps. If necessary, readjust the reduction first.

Wire bending in hybrid external fixation enlarge

Bending the wires

Cut and bend the wires. The sharp end can be bent into a space on the clamp. Alternatively, the sharp end can be covered with a protective cap, and bent to avoid prominence.

Example of hybrid external fixation enlarge

Example of final construct.

v2.0 2018-11-12