Executive Editor: Ernst Raaymakers, Joseph Schatzker, Rick Buckley

Authors: Matthias Hansen, Rodrigo Pesantez

Proximal tibia Extraarticular fracture, metaphyseal simple - Ring external fixator

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1 Principles top


Anatomical considerations

A thorough knowledge of the anatomy is mandatory to perform the correct placement of the K-wires. All important neurovascular structures run in the posterior half of the cross section.


Wires should be positioned as proximal as possible but not through the joint. The most proximal wire should be at least 14 mm below the articular surface because of the distal capsular insertion.

2 Patient preparation top


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

3 Ring application to proximal fracture fragment top

Carefully choose wire corridors. enlarge

Anatomical considerations

As wires go through both cortices, good knowledge of anatomy is mandatory (see the safe zones). Carefully choose wire corridors. At least two wires have to be used.

Insert wires. enlarge

Insert wires

For extraarticular fractures at least two standard wires are inserted.

Connect wires with ring. enlarge

Connect wires with ring

Connect the wires with the ring and tighten clamps.

4 Inserting pins into tibial shaft top

Tibial mid shaft level enlarge

Anatomical considerations

Mid shaft level
The neurovascular bundle (the anterior tibial artery and vein together with the deep peroneal nerve) run anterior to the interosseous membrane close to the posterolateral border of the tibia.

They are at risk if the pin is inserted in the direction as indicated by the red dotted line approximately half way between the anterior crest and the medial edge of the tibia.

Tibial distal shaft level enlarge

Distal shaft level
When inserting pins in the distal zone take into account the position of the anterior tibial artery and vein. Percutaneous insertion of pins in this area is dangerous. A minimal incision will allow preparation and safe insertion.

The peroneal bundle is located very close to the posterolateral border of the tibia and therefore at risk if pins are inserted in this direction.

Pins at this level should be inserted as shown in the illustration from anteromedial to posterolateral. A second pin can be inserted from medial to anterolateral, ventral to the fibula.

Schanz screw insertion enlarge

Standard Schanz screws

Drill through both cortices with a 3.5mm drill bit.
Use measuring device to determine diameter of bone.
Insert Schanz screws.

Proper pin insertion depth enlarge

Pin insertion depth

Make sure that the Schanz pins are not penetrating excessively through the far cortex, so as to avoid injury to either the neurovascular structures or soft tissues.

Image intensification control in two planes is recommended.

Choose safe locations for pin insertion. enlarge

Insert pins

Insert four pins into the tibia two at each level.
Place the proximal Schanz pins as close as possible to the fracture. The second Schanz pin pair must be positioned as distally as possible. The further the pin pairs are apart, the more stable the construction will be.

5 Finalizing the external fixator top

Frame construction enlarge

Frame construction

Connect the Schanz screws with the two rings. Then, interconnect all three rings with tubes. The clamps are left loose to allow manipulation.

Reduction enlarge


Use the rings to reduce the fracture by manipulation under image intensification.



After successful reduction, tighten clamps.

v2.0 2010-05-15