34: External Fixation of Distal Tibial Fractures

PROCEDURE 34 External Fixation of Distal Tibial Fractures



Jeremy A. Hall



image


Indications



image “Damage control” temporary fixation of fractures with severe soft tissue compromise such as open fractures or significant soft tissue swelling

image Definitive fixation of contaminated, infected fractures, or fractures associated with severe soft tissue injuries



PITFALLS



• The use of external fixation for temporary care of distal tibial fractures may lead to colonization or contamination of the surrounding soft tissues and may compromise alternate definitive care.



Controversies



• Controversy exists as to the role of external fixation of distal tibial fractures with severe soft tissue injury: temporary versus definitive care.



Treatment Options



• Early definitive treatment with an intramedullary nail or a plate-and-screws construct may be preferred if the soft tissues are amenable.


Examination/Imaging



image Status of the soft tissues
• Open wounds

• Severe soft tissue contusion, soft tissue swelling

image Neurovascular examination with careful documentation

image Anteroposterior (Fig. 1A) and lateral (Fig. 1B) radiographs of the tibia, as well as anteroposterior, lateral, and mortise views of the ankle (Fig. 2)

image Computed tomography scanning of the tibial plafond if intra-articular extension is suspected

image

FIGURE 1


image

FIGURE 2



Surgical Anatomy



image Anatomic “safe zones” have been defined based on cross-sectional studies (Fig. 3).
• The proximal tibial metaphysis offers a 220° anterior arch of safe pin site insertion.

• The remainder of the tibia provides 120–140° of anteromedial safe entry.

image

FIGURE 3




PEARLS



• Regional anesthesia may limit evaluation of compartment syndrome postoperatively.

• A bump under the buttock will rotate the limb out of external rotation.


Positioning



image General anesthesia is preferred.

image The patient is positioned supine on a radiolucent operating table with positioning aids, bumps, or a frame under the affected limb (Fig. 4).

image A tourniquet is applied, and the limb is prepped and draped free.

image

FIGURE 4




Equipment



• Rolled sterile towels and gowns or a prefabricated knee frame can aid in fracture reduction and alignment.



Controversies



• A fracture table can aid in fracture alignment, although positioning unavoidably prolongs the procedure.


Portals/Exposures



image In the majority of settings, stab wounds are made about the tibia, calcaneus, and first metatarsal to facilitate pin insertion (Fig. 5).

image Fibular fractures amenable to fixation are approached from the lateral subcutaneous border (Fig. 6).

image Intra-articular plafond fractures are addressed either percutaneusly or with a formal anterolateral or medial approach as necessary and as the soft tissues allow.

image

FIGURE 5


image

FIGURE 6




Instrumentation



• Cannulated small-fragment srews can be an asset in the fixation of intra-articular fractures of the plafond.

Related posts:

16: Perilunate Injuries 1: Open Reduction and Plate Fixation of Displaced Clavicle Fractures 7: Supracondylar Humeral Fractures 18: Femoral Neck Fractures: Arthroplasty 8: Terrible Triad Injuries of the Elbow 5: Humeral Shaft Fractures

Stay updated, free articles. Join our Telegram channel
Tags:
Jun 7, 2016 | Posted by in ORTHOPEDIC | Comments Off on 34: External Fixation of Distal Tibial Fractures

Full access? Get Clinical Tree
Get Clinical Tree app for offline access