External Fixation Tibia Fracture
Benjamin Shore, MD, MPH, FRCSC
Indications
Diaphyseal, proximal, or distal metadiaphyseal tibia fracture
Closed unstable fracture pattern (comminuted, long oblique, butterfly fragment)
Open fracture
Other wounds or skin-related issues which prevent casting or open treatment
Ages: All
Sterile Instruments/Equipment
Standard external fixator set
Circular external fixator set (Figure 25-11)
Radiolucent table
Patient Positioning (Figure 25-12)
Supine on the radiolucent table.
Bump underneath ipsilateral buttocks to prevent external rotation of operative leg
Avoid malrotation by placing the hip and the knee directly pointing to the ceiling. Look longitudinally from the foot and the limb position of the anterior hip and anterior knee should match and make sense. Significant internal or external rotation of the foot and the distal fracture should be a cause of concern and reevaluation.
Complete fluoroscopic AP and lateral views at the knee, fracture, and ankle to assure ability to visualize tibia completely and obtain provisional reduction
 Figure 25-11 ▪ Basic circular ring set. |
 Figure 25-12 ▪ Intraoperative set-up for placement of external fixator. Note the fluoroscopic machine comes from the lateral side. |
Surgical Approaches
Generally, in open fractures where the fracture ends need to be exposed and cleaned, the use of a uniplanar standard external fixator is easiest as the fracture can be manually reduced and held with reduction clamp, while the frame is placed and tightened.
In cases of closed injuries where reduction is unable to be maintained/obtained, then use of a circular fixator (Taylor spatial frame) is preferable as a preliminary reduction and gradual reduction can be done by using the program with strut lengthening or shortening to achieve anatomic reduction safely over time.
Reduction and Fixation Techniques
Uniplanar fixators:
Most tibia fractures can be managed with two half-pins in each segment and 2 bars. Rigidity may be added by spacing pins apart, multiplanar direction of half-pins, placing the bars closer to the skin (Figure 25-13A and B).
Fluoroscan should be used to mark fracture as the optimal spread of half-pins will be a half-pin at each segment close to the fracture and then a second half-pin per segment farther away (Figure 25-14).
Half-pin placement can be performed by making a 1 cm incision and spreading to bone, followed by predrilling the half-pin. In uniplanar frames, pins should be either directed anterior to posterior or perpendicular to the medial border of the tibia which is usually 45° from direct anterior (Figure 25-15A and B).
Take care to drill directly perpendicular to tibia in order for all pins to line up and not skive off the bone. Place the half-pin through the drilled site taking care to obtain bicortical purchase (Figures 25-16, 25-17, 25-18, 25-19A and B).
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