Threaded, titanium, half pins and/or tensioned 1.8-mm diameter stainless-steel wires were designed to be used with the Spatial Frame. To minimize the number of pins and wires, their placement should be optimized to provide the greatest stability within anatomic constraints. The entire length of the anterior/medial tibia is available for half pin fixation. Four millimeter and 5-mm titanium half pins are used for adolescents and small adults. Usually 6-mm half pins are used in large children and adults.

Long fragments are fixed with at least two and often three half pins in different planes. Pins should be spread longitudinally along a significant portion of each fragment but out of the zone of soft-tissue injury (Fig. 30.8). Obviously this is not always possible.

Shorter peri-articular fragments are fixed with at least two multiplanar half pins at approximately 70 degrees to each other. Adding a single olive wire in the coronal plane adds significant stability to a short fragment.

Alternatively, three 1.8-mm olive wires can be used to stabilize a short proximal or distal fragment (Fig. 30.9). The crossing angle of these wires must be optimized within anatomic limits. Olives should block the fragment from each side and the third olive wire should be blocking the fracture obliquity. Stability for a very short proximal tibial fragment

can be increased by transfixing the tibia and fibula at the level of the fibular head with a tension wire.

For very short, distal, tibial fragments, transosseous wires can be used as needed in the syndesmotic region. Intermediate length fragments may be fixed with a combination of wires and half pins.

The foot may also be included at least temporarily for fracture stability, soft tissue immobilization, and prevention of equinus contracture. A distal shaft fracture with significant soft-tissue injury and especially with peripheral nerve injury or closed head injury should have the fixation extended to the foot at least temporarily (Fig. 30.10). The foot plate is attached to the distal ring of the Spatial Frame with threaded rods. Usually a combination of olive wires and half pins are placed in the calcaneus and two wires are placed in the metatarsals (Fig. 30.11). Shorter frames may be constructed with short body struts. Tapered
and open-section frames may be applied. Segmental fractures are usually treated with a ring or 2/3 ring for each major fragment (Fig. 30.12).

Oblique fracture stability can be improved by using steerage pins on either side of the fracture (1). These pins should be angled 15 to 20 degrees from the transverse plane along the plane of the fracture (Fig. 30.13). These pins will cause dynamic interfragmentary compression
with weight bearing and minimize fracture shear. It is still beneficial if only one steerage pin is used.

General, spinal, or continuous epidural anesthetics may be used as indicated. The patient is positioned supine on a padded radiolucent table top. The most user-friendly tables contain no metal rails (even peripherally) to interfere with visualization with the image intensifier. The image intensifier should be positioned on the opposite side of the injury. A well-padded tourniquet is placed about the proximal thigh but generally is only used during debridement of open fractures. Even if used for debridement, the tourniquet should be deflated prior to pin and wire insertion. Longitudinal traction through a calcaneal wire may be used to improve overall alignment, but it is rarely used. A few folded towels are used to elevate the leg segments as needed as the frame is applied.

Pin and wire location and insertion technique are some of the most important factors for patient tolerance, frame longevity, and minimization of need for additional surgery. Bayonet point wires with cutting relief are the safest for metaphyseal and especially diaphyseal bone (Fig. 30.14). Wires are inserted percutaneously to the near cortex, then slowly drilled across both cortices with frequent pauses to prevent overheating, and tapped through the far soft tissue. The wire is bathed in saline for additional cooling. The surgeon should strive to achieve bicortical purchase with wires and pins to enhance mechanical purchase and decrease thermal necrosis. If burned bone is in the flutes of the predrill for half pins or on the tip of the emerging bayonet tipped wire, do not use that pin or wire. The small incision to insert the drill sleeve or release the skin for the olive is closed with a simple suture.

The Spatial Frame is assembled with two rings and six medium FastFx struts in their unlocked position (see Fig. 30.7). After choosing the approximate level for one ring, the surgeon marks the skin. Then the surgeon marks the skin 18 cm away for the position of the second ring (Fig. 30.15). The surgeon then slides the frame onto the leg (Fig. 30.16). The frame need not be centered longitudinally over the fracture. Make a short longitudinal incision
for a sagittal-plane half pin. Using a five-hole Rancho Cube as a drill guide (Fig. 30.17), the surgeon drills a pilot hole for the half pin. After inserting the half pin (Fig. 30.18), the surgeon attaches it to an appropriate length Rancho Cube while maintaining the desired soft-tissue clearance (Fig. 30.19). The Rancho Cube is attached to the Spatial Ring via the inner tier of holes at the anterior position (Fig. 30.20) on the master tab, the junction of the no. 1 and no. 2 struts. Using as long a Rancho Cube as possible, the surgeon inserts a half pin in the anterior-medial plane off the proximal face of the proximal ring (Fig. 30.21). Using a Rancho Cube as a drill guide (Fig. 30.22), the surgeon inserts a half pin in the sagittal plane on the proximal portion of the distal fragment (Fig. 30.23). Maintaining 1 to 2 fingerbreadths of soft-tissue clearance, the surgeon then attaches the Rancho Cube to the pin in the distal fragment (Fig. 30.24). The Rancho Cube is attached to the distal ring in the anterior hole (Fig. 30.25).