Principles of Tibial Fracture Management with Circular External Fixation

There is a growing mass of literature to suggest that circular external fixation for high-energy tibial fractures has advantages over traditional internal fixation, with potential improved rates of union, decreased incidence of posttraumatic osteomyelitis, and decreased soft tissue problems. To further advance our understanding of the role of circular external fixation in the management of these tibial fractures, randomized controlled trials should be implemented. In addition to complication rates and radiographic outcomes, validated functional outcome tools and cost analysis of this method should be compared with open reduction with internal fixation.

Key points

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Although circular external fixation is infrequently used for definitive management of tibia fractures, high-energy injuries with significant soft tissue damage and segmental bone loss are well managed with this technique.
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The biomechanical properties of the ring fixator are a result of high-tension transosseous wires allowing for axial micromotion with tremendous coronal and sagittal plane stability.
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In periarticular fractures the articular surface should be reconstructed anatomically by either capsuloligamentotaxis and olive wires or limited internal fixation in combination with wires.
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Frame construction should be based off the metaphyseal reference wire. Olive wires can be used to buttress fracture fragments. Half pins should be used to control and stabilize diaphyseal bone segments. The half pins should be placed in a divergent fashion to further enhance fixation stability.
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A growing body of literature suggests that treatment of high-energy tibial fractures with circular external fixation results in high union rates with limited additional soft tissue complications. There is a lack of long-term studies and quality of life–related outcomes in these patients.