Executive Editor: Peter Trafton

Authors: Theerachai Apivatthakakul, Surapong Anuraklekha, George Babikian, Fabio Castelli, Antonio Pace, Vajara Phiphobmongkol, Raymond White, Kodi Kojima, Matthew Camuso

Tibial shaft 42-C1 CREF

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Glossary

Author: Dankward Höntzsch

1 Note on illustrations top

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Throughout this treatment option illustrations of generic fracture patterns are shown, as four different types:

A) Unreduced fracture
B) Reduced fracture 
C) Fracture reduced and fixed provisionally 
D) Fracture fixed definitively

2 Principles of uniplanar external fixation top

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The frame of a uniplanar external fixator consists of at least two pins in each main fracture fragment connected with one single rod. A second rod may be added to increase stiffness of the frame.

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

Specific considerations for the uniplanar external fixator in the tibial shaft are given below.

3 Reduction (tibial shaft) top

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Apply manual longitudinal traction to leg and maintain reduction.

4 Pin insertion (tibial shaft) top

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Pin placement

For safe pin placement make use of the safe zones and be familiar with the anatomy of the lower leg.

Pearl
The pin in the distal tibia should be placed far away from the extensor tendons on the medial side.


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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.

5 Frame construction / fixation (tibial shaft) top

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Pin insertion and frame assembly

Insert a pin into each main fragment in one plane.

Connect the pins with one rod to which 4 clamps have been added.

At this point, some correction to the reduction is still possible.

Tighten the clamps.


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On both sides of the fracture, add an additional pin close to the fracture zone using the rod-to-pin clamps as guides.

Tighten the clamps.

Subsequent correction of the reduction is now impossible.


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Additional rod

If stability is not sufficient, an additional rod can be added. The stiffness of the construct is increased if the rods are closer to the bone, and the further apart from each other the rods are placed.


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Pearl: Prevent plantar flexion contracture

In patients with severe soft-tissue involvement, it may be helpful to add a pin in the foot (one of the tarsal or metatarsal bones) to maintain the ankle at a 90° angle. Thereby a plantar flexion contracture can be prevented.

The pin may be inserted in either the navicular bone, in one of the cuneiforms, in the first metatarsal base, or in the first and fifth metatarsal base, and connected to the tibial external fixator. Care should be taken to insert the pin bicortically and to avoid the intra-articular spaces.

v2.0 2016-10-17