The index surgery is usually performed within hours of presentation, whether the patient is seeking initial treatment of the injury or has been referred from elsewhere. Early external fixation allows for earlier definitive
treatment and better surgical outcome, but the Schanz pins must be placed carefully, avoiding neural and vascular structures. Open fractures have external fixation applied at the time of initial irrigation and débridement.

Any fibular injury present is addressed first, using standard techniques. The key to the restoration of fibular anatomy is achieving correct fibular length, orientation, and rotation with the application of appropriate implants.¹ To restore normal ankle mechanics, most displaced fibular fractures require reduction, but fibular reduction is especially critical when these fractures are associated with tibial plafond injuries because the posterior (Volkmann) fragment is connected to the fibula via the posterior tibiofibular ligament. Unless this ligament is avulsed, reduction of the fibula will grossly reduce the Volkmann fragment, facilitating treatment of the tibial plafond. Consequently, fibular reduction is a critical step in the treatment of these fractures, and a less than anatomic fibular reduction is detrimental to the patient’s outcome. Nonanatomic reductions must be revised, and the initial incision damages the soft-tissue envelope, making the revision more difficult. Although external fixation should be applied as soon as possible to minimize soft-tissue trauma, fibular fixation can wait until personnel with adequate training and equipment are available, which may require transfer from the referral center.

After the fibular fracture has been treated, an external fixation frame is attached. No tourniquet is used. The most basic frame is one applied along the medial column (Figure 4, A), but lateral injuries may require the addition of an additional bar, which makes a bicolumnar frame (Figure 4, B). The medial column frame is attached to the tibia, calcaneus, and cuneiforms. Four pins are placed to support the bar(s) through small incisions that follow the line of distraction. All pins are located outside of the anticipated location of the surgical incisions for definitive fracture treatment.

The calcaneal pin is inserted first. For medial column frames, the calcaneal pin is terminally threaded; for bicolumnar frames, the pin is centrally threaded (no
threads on the ends). No predrilling is required. The pin is inserted from the medial surface of the calcaneus and, for bicolumnar frames, protrudes through the lateral surface of the foot. The calcaneal pin is placed in the posterior portion of the calcaneal tuberosity, posterior to a line that connects the superior and posterior edges. Placement of the calcaneal pin through this region will avoid the sural nerve and calcaneal branch of the tibial nerve.

The second pin is then inserted into the tibia; this is located at the proximal middle third junction of the tibia through its anteromedial surface, avoiding the saphenous nerve and vein. The proximal tibial pin is a 5-mm Schanz half pin (designed for bicortical applications). Predrilling is required for both tibial pins.

The third pin is inserted via a percutaneous stab wound through the medial surface of the medial cuneiform. This pin goes through the medial and intermediate cuneiforms and into the lateral cuneiform, but it does not transgress the base of the second metatarsal. No predrilling is required.

The final pin is the distal tibial pin, which is similar to the proximal tibial pin. Its location is determined by
the tibial fracture. The pin should be located as distally as possible while remaining outside of the fracture area and forthcoming internal fixation.