This page is part of the Humeral Fracture Fixation syllabus by Medical Makers for the Global Surgical Training Challenge.This page is not open edit.Read more...
Tibial Fracture Fixation Team Logo.jpg
FA info icon.svg Angle down icon.svg Medical skill data
Part of Humeral Fracture Fixation
Required time 1 hour
Equipment 3D Printed Adult Male Humeral Bone Models
Arbutus Medical HEX Drill Kit
Tibial Shaft Transverse Fracture Simulator

Caption underneath

This skills module allows medical officers and surgeons who are not orthopedic specialists to become confident and competent in performing irrigation and debridement, power and manual drilling, proper positioning and insertion of Schanz screws, construction of the rod-to-rod modular frame, and fracture reduction and stabilization as part of external fixation procedures for open humeral shaft fractures performed in regions without specialist coverage. To maximize patient safety, this module teaches learners to use a powered drill to insert self-drilling Schanz screws through the near cortex and then manually advance Schanz screws into the far cortex to avoid plunging. The Humeral Shaft Transverse Fracture Simulator is designed to simulate the right humerus of a patient in the supine position.

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It's highly recommended that the learner has prior clinical experience with modular external fixation of an open tibial shaft fracture before undertaking this simulation skills training because humeral fracture fixation is more technically advanced and poses a higher risk of complications compared to tibial fracture fixation.

Learning Objectives[edit | edit source]

Training Objectives[edit | edit source]

By the end of this module, learners will be able to perform the following procedural steps on the right humerus of a simulated supine patient:

  1. Perform wound debridement using an average of 3L of irrigation solution for each successive Gustilo Type (i.e., 6L for Gustilo Type II open humeral fracture and 9L for Gustilo Type III open humeral fracture) to reduce the risk of infection.*[1][2][3]
  2. Debride all foreign material and non-viable tissue to reduce the risk of infection and minimize wound complications.*[3][4]
  3. Insert the Schanz screws into the safe zones of the humerus to reduce the risk of damage to neurovascular structures by placing the pins anterolaterally in the proximal fragment and laterally in the distal fragment when the patient is supine.[5][6][7][8]
  4. Position the “far” Schanz screw (furthest from the fracture line) in the proximal fragment 7 cm below the acromion while avoiding traumatized soft tissues to avoid damage to the axillary nerve and the tendon of the biceps.*[9][10]
  5. Place the two “near” Schanz screws (closest to the fracture line) at least 2.0 cm (a finger breadth) from the fracture line while avoiding traumatized soft tissues to help prevent the placement of the Schanz screw within the fracture hematoma and risk having a pin site infection spread within the fracture.[11]
  6. Place the "far" Schanz screw in the distal fragment at least two fingers’ breadth proximal to the lateral epicondyle to avoid entry into the elbow joint (olecranon fossa).[12]
  7. In the proximal fragment, use a scalpel to make a stab incision in the skin overlying the anterolateral wall of the humerus for the near and far Schanz screws and use dissecting scissors to spread the soft tissue apart in each incision to expose the bone for drilling.*[13][14]
  8. In the distal fragment, use the scalpel to make a lateral skin incision large enough to accommodate two pins and permit palpation and/or direct visualization of the radial nerve (which is in close relationship with the dorsal diaphyseal cortex) to reduce the risk of radial nerve injury.*[15][16]
  9. In the distal fragment, use dissecting scissors in the incision to spread the soft tissues apart to palpate and/or visualize the radial nerve, and expose the bone for drilling.*

10. In the distal fragment, pins may be inserted in divergent directions to minimize the size of the incision while permitting better control of displacing forces to optimize stabilization of the reduction.[17]

11. Prepare the powered surgical drill for use by inserting a Schanz screw into the powered surgical drill, inserting the chuck key into the opening in the drill, turning the chuck key clockwise to tighten the drill over the Schanz screw, and then engaging the switch for forward drilling direction.

12. Test the powered surgical drill is ready for use by pressing the on/off trigger and confirm that the Schanz screw tip is rotating clockwise when the drill is pointing forward.

13. Use the properly sized drill sleeve for the Schanz screws, place the drill sleeve with the trocar directly on the near cortex, remove the trocar from the drill sleeve, insert the Schanz screw into the drill sleeve, and hold the drill sleeve directly on the near cortex for each pin insertion site to prevent damage to soft tissue and neurovascular structures during drilling.*[13][18]

14. Direct an assistant to perform irrigation while drilling to reduce the risk of thermal osteonecrosis.*[19]

15. Place the Schanz screw tip on the near cortex, start drilling with the screw tip rotating in a clockwise direction, and ensure that the tip does not slip on the near cortex which can injure the surrounding soft tissues.[13][20]

16. Power drill each Schanz screw through the near cortex and use tactile feel and acoustic feedback to stop drilling after passing through the near cortex and before or when the inner surface of the far cortex is reached to avoid plunging through the far cortex and damaging underlying neurovascular structures and soft tissues.[13][21]

17. Use the chuck key to detach the powered surgical drill from each Schanz screw, and remove the drill sleeve from each Schanz screw.

18. Slide the universal chuck with T-handle over the Schanz screw, and use the chuck key to tighten the chuck over each Schanz screw.

19. Use the universal chuck with T-handle to turn each Schanz screw manually for one to two 360 degree rotations so the tip of each Schanz screw does not perforate the far cortex because deep placement of the screw tip can injure the medial neurovascular bundle in the proximal fragment and the median nerve or brachial artery in the distal fragment.[22][23]

20. Detach the universal chuck with T-handle from each Schanz screw.

21. Apply the pin-to-rod clamps to connect the two Schanz screws in each main fragment to a 150 mm rod.[13]

22. Tighten the pin-to-rod clamps initially by hand and then apply and turn the 11 mm spanner with T-handle wrench clockwise for final tightening.

23. Apply the rod-to-rod clamps to loosely fix the 100 mm connecting rod to interconnect the two 150 mm rods for the proximal and distal fragments.

24. Use the two 150 mm rods as handles to manually reduce the fracture and restore alignment.

25. Manipulate the two near Schanz Screws to compress the fragments together.

26. Direct an assistant to stabilize the reduced fracture while using the 11 mm spanner with T handle wrench for final tightening of the rod-to-rod clamps around the 100 mm connecting rod.

27. Verify the reduction visually to confirm whether the alignment is within acceptable parameters.

  • > 50% bone apposition
  • < 15° malrotation (at 0° of rotation the patient's palm is facing straight up towards the ceiling when the patient is supine and the forearm is supinated)*
  • < 20° anterior angulation
  • < 30° varus/valgus angulation
  • < 3 cm shortening (cannot be measured intraoperatively)*[24][25][26][27][28]

28. If required, adjust the fragments to achieve an adequate reduction.

  • > 50% bone apposition
  • < 15° malrotation (at 0° of rotation the patient's palm is facing straight up towards the ceiling when the patient is supine and the forearm is supinated)*
  • < 20° anterior angulation
  • < 30° varus/valgus angulation
  • < 3 cm shortening (cannot be measured intraoperatively)*[24][25][26][27][28]

29. Inspect the pin sites for skin tenting and if present, the stab incision should be widened to release any soft tissue tension around the pin site to reduce the risk of inflammation and pin infection.*[29]

30. Clean the extremity and apply sterile gauze dressings to all four pin sites at the end of the procedure.*

31. Re-evaluate the Gustilo open-fracture classification for the open tibial fracture in the operating room, and update the antibiotic regimen and surgical treatment plan accordingly.*[3][30][31][32][33][34]

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The steps above highlighted with an asterix (*) cannot be performed during simulation training but must be performed during the actual clinical procedure.

Knowledge Objectives[edit | edit source]

By the end of the module, the learner should know to perform the following steps in the actual clinical procedure:

  1. Position patient in the supine position with the forearm supinated and palm facing up towards the ceiling.
  2. When the patient is supine, inserting Schanz screws into the safe zone of the distal third of the humerus is not feasible and the posterior aspect of the middle third of the humeral shaft is not accessible making injury to the radial nerve in this region unlikely.[35]
  3. Irrigate a Gustilo Type II open humeral shaft fracture with an average of 6 L of irrigation solution and Gustilo Type III open tibial shaft fracture with an average of 9 L of irrigation solution to reduce the risk of osteomyelitis.
  4. Debride all foreign material and non-viable tissue to reduce the risk of infection and minimize wound complications.
  5. Position the “far” Schanz screw (furthest from the fracture line) in the proximal fragment 7 cm below the acromion while avoiding traumatized soft tissues to avoid damage to the axillary nerve and the tendon of the biceps.
  6. In the proximal fragment, use a scalpel to make a stab incision in the skin overlying the anterolateral wall of the humerus for the near and far Schanz screws and use dissecting scissors to spread the soft tissue apart in each incision to expose the bone for drilling.
  7. In the distal fragment, use the scalpel to make a lateral skin incision large enough to accommodate two pins and permit palpation and/or direct visualization of the radial nerve to reduce the risk of radial nerve injury.
  8. In the distal fragment, use dissecting scissors in the incision to spread the soft tissues apart to palpate and/or visualize the radial nerve, and expose the bone for drilling.
  9. Hold the drill sleeve directly on the near cortex for each pin insertion site to prevent damage to soft tissue and neurovascular structures during drilling.

10. Direct an assistant to provide irrigation while drilling is performed to reduce the risk of thermal osteonecrosis.[19]

11. Verify the reduction visually to confirm whether the alignment is within acceptable parameters.

  • < 15° malrotation (at 0° of rotation the patient's palm is facing straight up towards the ceiling when the patient is supine and the forearm is supinated)
  • < 3 cm shortening (cannot be measured intraoperatively)

12. If required, adjust the fragments to achieve an adequate reduction.

  • < 15° malrotation (at 0° of rotation the patient's palm is facing straight up towards the ceiling when the patient is supine and the forearm is supinated)*
  • < 3 cm shortening (cannot be measured intraoperatively)

13. Inspect the pin sites for skin tenting and if present, the stab incision should be widened to release any soft tissue tension around the pin site to reduce the risk of inflammation and pin infection.

14. Clean the extremity and apply sterile gauze dressings to all 4 pin sites at the end of the procedure.

15. Re-evaluate the Gustilo open-fracture classification for the open humeral fracture in the operating room, and update the antibiotic regimen and surgical treatment plan accordingly.

Materials and Equipment[edit | edit source]

1
Modular External Fixation Hardware Courtesy of Medical Aid International and Dr. Habila Umaru
Modular External Fixation Hardware
  • Triple drill sleeve assembly, 5.0 mm
  • Self-drilling Schanz screws, 5.0 mm diameter, Quantity: 4
  • Chuck key for universal chuck with T-handle
  • Universal chuck with T-handle for 5.0 mm Schanz screws
  • Pin-to-rod clamps for 11 mm diameter rods and 5.0 mm Schanz screws, Quantity: 4
  • 150 mm rods, 11 mm diameter for clamps designed for 5.0 mm Schanz screws, Quantity: 2
  • Rod-to-rod clamps for 11 mm diameter rods, Quantity: 2
  • 100 mm connecting rod, 11 mm diameter
  • 11 mm spanner with T-handle wrench

It is also possible to use 4.5 mm diameter self-drilling Schanz screws for this skills simulation training. However, this requires using a 4.5 mm drill sleeve instead of a 5.0 mm drill sleeve.

2
Surgical Supplies for Humeral Fracture Fixation
Surgical Supplies
  • Eye protection
  • Gloves
  • 50 mL syringe*
  • Scalpel handle with 22 blade*
  • Dissecting scissors*
  • Chuck key for powered surgical drill
  • Any powered surgical drill compatible with 5.0 mm diameter Schanz screws
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The items above highlighted with an asterix (*) are not used in this simulation training but are used during the actual clinical procedure.

3
Humeral Shaft Transverse Fracture Simulator Secured to Wood Board
Humeral Shaft Transverse Fracture Simulator

The Humeral Shaft Transverse Fracture Simulator will be positioned so the fracture ends are slightly distracted by 2.0 to 3.0 mm.

4
Self-Assessment Framework Supplies
  • Ruler
  • Clipboard
  • Training Logbook (please click on this link to print out the Training Logbook)
  • Pen
  • Any cellphone with a camera

Procedure Steps[edit | edit source]

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Annotations:
  • 00:00 Irrigate and Debride Open Wounds
  • 00:13 Position Far Schanz Screw in the Proximal Fragment 7 cm Below the Acromion (Not Shown)
  • 00:31 Power Drill Far Schanz Screw Anterolaterally Into Proximal Fragment
  • 01:05 Manually Advance Far Schanz Screw Into Far Cortex of Proximal Fragment
  • 01:34 Position Near Schanz Screw in the Proximal Fragment At Least 2 cm From the Fracture Line
  • 01:53 Power Drill Near Schanz Screw Anterolaterally Into Proximal Fragment
  • 02:31 Manually Advance Near Schanz Screw Into Far Cortex of Proximal Fragment
  • 02:59 Make a Lateral Skin Incision in the Distal Fragment to Accommodate Two Pins and Permit Palpation or Visualization of the Radial Nerve (Not Shown)
  • 03:32 Position Far Schanz Screw in the Distal Fragment at Least Two Fingers' Breadth Proximal to the Lateral Epicondyle
  • 03:46 Power Drill Far Schanz Screw Laterally Into Distal Fragment
  • 04:03 Manually Advance Far Schanz Screw Into Far Cortex of Distal Fragment
  • 04:32 Position Near Schanz Screw in the Distal Fragment At Least 2 cm From the Fracture Line Note: In the Distal Fragment, Pins May Be Inserted in Divergent Directions to Minimize the Size of the Incision While Optimizing Stabilization of the Reduction
  • 04:51 Power Drill Near Schanz Screw Laterally Into Distal Fragment
  • 05:17 Manually Advance Near Schanz Screw Into Far Cortex of Distal Fragment
  • 05:43 Use Pin-To-Rod Clamps to Fix Rods in Parallel to Each Fragment
  • 06:52 Use Rod-To-Rod Clamps to Loosely Fix Connecting Rod from Rod to Rod
  • 07:22 Loosen Right Vise Clamp Securing the Distal Fragment to Simulate a Displaced Fracture
  • 07:42 Use Rods and Schanz Screws to Reduce and Compress Fracture
  • 07:52 Stabilize and Inspect Reduction
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The bulleted steps below highlighted in bold and with an asterix (*) are considered as critical for the procedure and for which only essential conversations and activities in the operating room should occur to avoid distracting the surgical practitioner from their performance of his or her duties.[36]

1
Start this procedure with the simulator fragments slightly distracted by 2.0 - 3.0 mm but otherwise properly aligned to simulate a fracture with restored angulation, and rotation.
Irrigate and Debride Open Wounds

1. Start this procedure with the simulator fragments slightly distracted by 2.0 - 3.0 mm but otherwise properly aligned to simulate a fracture with restored angulation, and rotation.

  1. Wear proper eye protection and gloves.
  2. Normally, an average of 3L of irrigation solution (distilled water or isotonic saline) is used for each successive Gustilo Type (i.e., 6L for Gustilo Type II and 9L for Gustilo Type III) for wound lavage of an open humeral fracture to reduce the risk of infection.[1][2][3] However, an empty syringe can be used to simulate wound lavage during this simulation training.
  3. Normally, all foreign material and non-viable tissue is debrided to reduce the risk of infection and minimize wound complications.[3][4][37] However, the simulator does not display foreign material or non-viable tissue so this step is skipped during this simulation training.
2
Insert Schanz Screws Into Safe Zones of the Humerus
  1. Insert the Schanz screws into the safe zones of the humerus to reduce the risk of damage to neurovascular structures by placing the pins anterolaterally in the proximal fragment and laterally in the distal fragment when the patient is supine.
  2. Position the “far” Schanz screw (furthest from the fracture line) in the proximal fragment 7 cm below the acromion while avoiding traumatized soft tissues to avoid damage to the axillary nerve and the tendon of the biceps. However, the simulator does not display the acromion so this step is skipped during this simulation training.
  3. Place the two “near” Schanz screws (closest to the fracture line) at least 2.0 cm (a finger breadth) from the fracture line while avoiding traumatized soft tissues. This helps prevent the placement of the Schanz screw within the fracture hematoma and risk having a pin site infection spread within the fracture.
  4. Place the "far" Schanz screw in the distal fragment at least two fingers’ breadth proximal to the lateral epicondyle to avoid entry into the elbow joint (olecranon fossa).
  5. Normally in the proximal fragment, (i) a 22 blade scalpel is used to make a stab incision in the skin overlying the anterolateral wall of the humerus for the near and far Schanz screws, and (ii) dissecting scissors are used to spread the soft tissue apart in each incision to expose the bone for drilling. However, the simulator does not have simulated soft tissue so these steps are skipped during this simulation training.
  6. Normally in the distal fragment, (i) a 22 blade scalpel is used to make a lateral skin incision large enough to accommodate two pins and permit palpation and/or direct visualization of the radial nerve (which is in close relationship with the dorsal diaphyseal cortex) to reduce the risk of radial nerve injury, and (ii) dissecting scissors are used in the incision to spread the soft tissues apart in the incision to permit the practitioner to palpate and/or visualize the radial nerve, and to expose the bone for drilling. However, the simulator does not have simulated soft tissue so these steps are skipped during this simulation training.
  7. In the distal fragment, pins may be inserted in divergent directions to minimize the size of the incision while permitting better control of displacing forces to optimize stabilization of the reduction.
3
Prepare for Power Drilling of Schanz Screws
  1. Insert a 5.0 mm diameter self-drilling Schanz screw into the powered surgical drill.
  2. Insert the chuck key into the opening in the drill (watch video from 1:11 to 1:15). Turn the chuck key clockwise to tighten the drill over the Schanz screw.
  3. Engage the switch for forward drilling direction on the drill. NOTE: Different drills have different locations for the switch that controls forward drilling direction.
  4. Press the on/off trigger to confirm that the drill is ready for use. The Schanz screw tip should be rotating in a clockwise direction when the drill is pointing forward.
  5. Use the correctly sized 5.0 mm drill sleeve for 5.0 mm diameter Schanz screws. If using 4.5 mm diameter self-drilling Schanz screws for this simulation training, this requires using a 4.5 mm drill sleeve instead of a 5.0 mm drill sleeve.
  6. Place the drill sleeve with the trocar directly on the near cortex, remove the trocar from the drill sleeve, insert the Schanz screw into the drill sleeve, and place the Schanz screw tip directly on the near cortex of the humerus.
  7. Normally, the drill sleeve is positioned directly on the near cortex for each pin insertion site to prevent damage to soft tissue and neurovascular structures during drilling.[13] However, the drill sleeve should be pulled back at least 3.0 mm above the near cortex once drilling has commenced during this simulation training to prevent plastic strands from getting stuck inside the drill sleeve.
4
Oscillogram of Bicortical Drilling of Tibial Fracture
Power Drill Schanz Screws Into Near Cortex
  1. Normally, irrigation should be provided when drilling is performed to reduce the risk of thermal osteonecrosis.[19] However, an assistant can simulate irrigation with an empty syringe while drilling is performed during this simulation training.

2. Place the Schanz screw tip on the near cortex of the humerus, start drilling with the screw tip rotating in a clockwise direction, and ensure that the tip does not slip on the near cortex.*

3. Power drill each Schanz screw through the near cortex of the humerus. Pay attention to the sound changes and tactile feel as the Schanz screw penetrates the near cortex.* The drilling sound will decrease in volume and a loss of resistance ("give") can be felt when the screw tip passes through the near cortex into the cancellous bone.

4. Stop power drilling after passing through the near cortex and before or when the inner surface of the far cortex is reached, which can be easily felt by a sudden resistance to the screw tip.* This prevents plunging through the far cortex and damaging underlying soft tissue.

  1. Insert the chuck key into the opening in the drill (watch video from 1:23 to 1:27), turn the chuck key anticlockwise, and detach the drill from the Schanz screw.
  2. Remove the drill sleeve from the Schanz screw.
5
Manually Advance Schanz Screws Into Far Cortex
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The protruding tip of the self-drilling Schanz screw can injure the underlying soft tissue.[38] Manual advancement of the Schanz screw reduces the risk of a Schanz screw perforating the far cortex and plunging into the soft tissue.

  1. Slide the universal chuck with T-handle over the Schanz screw.
  2. To tighten the chuck over each Schanz screw, (i) manually rotate the proximal part of the chuck clockwise (click here to watch 20 second video) or (ii) insert the chuck key into the opening in the chuck and turn the chuck key clockwise (click here to watch 19 second video).

3. Use the T-handle to turn each Schanz screw clockwise for one to two 360 degree rotations to anchor the screw tip into the far cortex without exiting the far cortex.*[38] Resistance can be felt when the Schanz screw is being anchored into the inner side of the far cortex.

  1. When manually advancing each Schanz screw into the far cortex, a loss of resistance ("give") should not be felt because this signifies that the Schanz screw has perforated the far cortex.
  2. To detach the chuck from each Schanz screw, (i) manually rotate the proximal part of the chuck anticlockwise (click here to watch 23 second video), or (ii) insert the chuck key into the small, circular opening in the chuck and turn the chuck key anticlockwise (click here to watch 13 second video).
6
Use Pin-To-Rod Clamps to Fix Rods in Parallel to Each Fragment
  1. Apply the pin-to-rod clamps to connect the two Schanz screws in each fragment to a 150 mm rod.[13]
  2. Tighten the pin-to-rod clamps initially by hand. Then apply and turn the 11 mm spanner with T-handle wrench clockwise for final tightening.
7
Use Rod-To-Rod Clamps to Loosely Fix Connecting Rod from Rod to Rod
  1. Apply the rod-to-rod clamps to loosely fix the 100 mm connecting rod to interconnect the 150 mm rods for the proximal and distal fragments.
8
Use Rods and Schanz Screws to Reduce and Compress Fracture
  1. Remove one nail in the vise attachment of the distal fragment or loosen the right vise clamp securing the distal fragment to simulate a displaced fracture.

2. Use the two 150 mm rods as handles to manually reduce the fracture and restore alignment

  • > 50% bone apposition
  • < 15° malrotation (at 0° of rotation the patient's palm is facing straight up towards the ceiling when the patient is supine and the forearm is supinated)
  • < 20° anterior angulation
  • < 30° varus/valgus angulation
  • < 3 cm shortening (cannot be measured intraoperatively)*
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Normally, restoration of rotational alignment is confirmed by visually checking the position of the palm.[24] However, the simulator does not include a hand so the humerus will be visually inspected to verify restoration of rotational alignment during this simulation training.

Normally, length discrepancy cannot be measured intraoperatively. However, the humerus can be visually inspected to verify restoration of limb length during this simulation training.

3. Manipulate the two near Schanz Screws to compress the fragments together

  • Length discrepancy < 3 cm shortening (cannot be measured intraoperatively)*
9
Stabilize and Inspect Reduction

1. The assistant will stabilize the reduced and compressed fracture by holding the two near Schanz screws in place while the surgeon uses the spanner with T handle wrench for final tightening of the rod-to-rod clamps around the 100 mm connecting rod.*

2. Verify the reduction visually to confirm whether the alignment is within acceptable parameters

  • > 50% bone apposition
  • < 15° malrotation (at 0° of rotation the patient's palm is facing straight up towards the ceiling when the patient is supine and the forearm is supinated)
  • < 20° anterior angulation
  • < 30° varus/valgus angulation
  • < 3 cm shortening (cannot be measured intraoperatively)*

Normally, restoration of rotational alignment is confirmed by visually checking the position of the palm.[24] However, the simulator does not include a hand so the humerus will be visually inspected to verify restoration of rotational alignment during this simulation training.

Normally, length discrepancy cannot be measured intraoperatively. However, the humerus can be visually inspected to verify restoration of limb length during this simulation training.

3. If required, adjust the fragments to achieve an adequate reduction

  • > 50% bone apposition
  • < 15° malrotation
  • < 20° anterior angulation
  • < 30° varus/valgus angulation
  • < 3 cm shortening (cannot be measured intraoperatively)*
10
Apply Dressing and Evaluate Extremity
  1. Normally, the pin sites are inspected for skin tenting. If skin tenting is present, the stab incision should be widened to release any soft tissue tension around the pin site to reduce the risk of inflammation and pin infection. However, the simulator does not have simulated soft tissue so this step is skipped during this simulation training.
  2. Normally, the extremity should be cleaned and sterile gauze dressings applied to all 4 pin sites at the end of the procedure. However, this step is skipped during this simulation training.
  3. Normally, the Gustilo open-fracture classification for the injury should be re-evaluated after debridement in the operating room, and the antibiotic regimen and surgical treatment plan updated accordingly.[30][31][32][33] If the injury is re-classified to a Gustilo Type IIIB or Type IIIC, then referral to a tertiary center with specialist care is warranted. A Gustilo Type IIIC injury is a surgical emergency. However, the simulator does not have simulated soft tissue so this step is skipped during this simulation training.

Gustilo Open-Fracture Classification[edit | edit source]

Gustilo Open-Fracture Classification[31][32]
Gustilo Type I: An open fracture with a wound less than 1 cm long and clean.
Gustilo Type II: An open fracture with a laceration more than 1 cm long without extensive soft tissue damage, flaps, or avulsions.
Gustilo Type IIIA: Adequate soft-tissue coverage of a fractured bone despite extensive soft-tissue laceration or flaps, or high-energy trauma irrespective of the size of the wound.
Gustilo Type IIIB: Extensive soft-tissue injury loss with periosteal stripping and bone exposure. This is usually associated with massive contamination.
Gustilo Type IIIC: Open fracture associated with arterial injury requiring repair.
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If the injury is re-classified to a Gustilo Type IIIB or Type IIIC, the patient should be referred to a tertiary center with specialist care. A Gustilo Type IIIC injury is a surgical emergency.

Self-Assessment Framework[edit | edit source]

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Self-assessment

After the reduced fracture has been stabilized with the modular external fixator, please go to this link to follow the instructions on how to use a cellphone to take 5 post-operative photos ("digital X-rays"), and complete the printed Training Logbook

Training Module Certificate of Completion[edit | edit source]

Once the self-assessment framework has been completed:

  1. Go to this link.
  2. Click on "Get your certificate" button under the "Menu" section in the upper right corner of the module page.
  3. Type in your name, download and print out a certificate of completion for this training module.
  4. Photograph your certificate on your cellphone as a backup and file the printed certificate in your training records.

Acknowledgements[edit | edit source]

This work is funded by a grant from the Intuitive Foundation. Any research, findings, conclusions, or recommendations expressed in this work are those of the author(s), and not of the Intuitive Foundation.

References[edit | edit source]

  1. ↑ 1.0 1.1 Olufemi OT, Adeyeye AI. Irrigation solutions in open fractures of the lower extremities: evaluation of isotonic saline and distilled water. SICOT J. 2017;3:7. doi: 10.1051/sicotj/2016031. Epub 2017 Jan 30. PMID: 28134091; PMCID: PMC5278649.
  2. ↑ 2.0 2.1 https://www.orthobullets.com/trauma/1004/open-fractures-management
  3. ↑ 3.0 3.1 3.2 3.3 3.4 https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/further-reading/principles-of-management-of-open-fractures?searchurl=%2fSearchResults#principles-of-surgical-care-for-open-fractures
  4. ↑ 4.0 4.1 https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/further-reading/principles-of-management-of-open-fractures?searchurl=%2fSearchResults#d-bridement
  5. ↑ https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/humeral-shaft/approach/safe-zones-for-percutaneous-pins-or-screws#safe-zone-in-the-proximal-third
  6. ↑ https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/humeral-shaft/approach/safe-zones-for-percutaneous-pins-or-screws#safe-zone-in-the-distal-third
  7. ↑ https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/humeral-shaft/approach/safe-zones-for-percutaneous-pins-or-screws#safe-zone-in-the-proximal-third
  8. ↑ https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/humeral-shaft/simple-fracture-transverse-less-than30/external-fixation#pin-insertion-humeral-shaft-
  9. ↑ https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/humeral-shaft/approach/safe-zones-for-percutaneous-pins-or-screws#safe-zone-in-the-proximal-third
  10. ↑ https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/basic-technique/basic-technique-modular-external-fixation#principles
  11. ↑ Encinas-Ullán CA, Martínez-Diez JM, Rodríguez-Merchán EC. The use of external fixation in the emergency department: applications, common errors, complications and their treatment. EFORT Open Rev. 2020 Apr 2;5(4):204-214. doi: 10.1302/2058-5241.5.190029. PMID: 32377388; PMCID: PMC7202044.
  12. ↑ https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/humeral-shaft/approach/safe-zones-for-percutaneous-pins-or-screws#safe-zone-in-the-distal-third
  13. ↑ 13.0 13.1 13.2 13.3 13.4 13.5 13.6 Höntzsch D. Modular External Fixator [Internet]. AO Foundation Surgery Reference. AO Foundation Surgery Reference; 2021 [cited 2021 Nov 28]. Available from: https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/tibial-shaft/simple-fracture-transverse/modular-external-fixator#principles-of-modular-external-fixation.
  14. ↑ https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/humeral-shaft/simple-fracture-transverse-less-than30/external-fixation#pin-insertion-humeral-shaft-
  15. ↑ https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/humeral-shaft/approach/safe-zones-for-percutaneous-pins-or-screws#no-safe-zone-in-the-middle-third
  16. ↑ https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/humeral-shaft/approach/safe-zones-for-percutaneous-pins-or-screws#safe-zone-in-the-distal-third
  17. ↑ https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/humeral-shaft/simple-fracture-transverse-less-than30/external-fixation#pin-insertion-humeral-shaft-
  18. ↑ https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/humeral-shaft/simple-fracture-transverse-less-than30/external-fixation#pin-insertion-humeral-shaft-
  19. ↑ 19.0 19.1 19.2 Timon C, Keady C. Thermal Osteonecrosis Caused by Bone Drilling in Orthopedic Surgery: A Literature Review. Cureus. 2019 Jul 24;11(7):e5226. doi: 10.7759/cureus.5226. PMID: 31565628; PMCID: PMC6759003.
  20. ↑ https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/tibial-shaft/simple-fracture-transverse/modular-external-fixator#pin-insertion-tibial-shaft-
  21. ↑ Khokhotva M, Backstein D, Dubrowski A. Outcome errors are not necessary for learning orthopedic bone drilling. Can J Surg. 2009 Apr;52(2):98-102. PMID: 19399203; PMCID: PMC2663499. URL: https://pubmed.ncbi.nlm.nih.gov/19399203/.
  22. ↑ https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/humeral-shaft/approach/safe-zones-for-percutaneous-pins-or-screws#safe-zone-in-the-proximal-third
  23. ↑ https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/humeral-shaft/approach/safe-zones-for-percutaneous-pins-or-screws#safe-zone-in-the-distal-third
  24. ↑ 24.0 24.1 24.2 24.3 Greene, W.B., Heckman, J.D., & American Academy of Orthopaedic Surgeons. (1994). The clinical measurement of joint motion. Rosemont, Ill: American Academy of Orthopaedic Surgeons.
  25. ↑ 25.0 25.1 Klenerman L. Fractures of the shaft of the humerus. J Bone Joint Surg Br. 1966 Feb;48(1):105-11. PMID: 5909054.
  26. ↑ 26.0 26.1 Spiguel AR, Steffner RJ. Humeral shaft fractures. Curr Rev Musculoskelet Med. 2012 Sep;5(3):177-83. doi: 10.1007/s12178-012-9125-z. PMID: 22566083; PMCID: PMC3535078.
  27. ↑ 27.0 27.1 https://www.orthobullets.com/trauma/1016/humeral-shaft-fractures
  28. ↑ 28.0 28.1 Casadei K, Kiel J. Anthropometric Measurement. [Updated 2022 Sep 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537315/
  29. ↑ https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/humeral-shaft/simple-fracture-transverse-less-than30/external-fixation#aftercare
  30. ↑ 30.0 30.1 https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/further-reading/principles-of-management-of-open-fractures?searchurl=%2fSearchResults#classification-of-open-fractures
  31. ↑ 31.0 31.1 31.2 Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am. 1976 Jun;58(4):453-8. PMID: 773941.
  32. ↑ 32.0 32.1 32.2 Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma. 1984 Aug;24(8):742-6. doi: 10.1097/00005373-198408000-00009. PMID: 6471139.
  33. ↑ 33.0 33.1 Garner MR, Sethuraman SA, Schade MA, Boateng H. Antibiotic Prophylaxis in Open Fractures: Evidence, Evolving Issues, and Recommendations. J Am Acad Orthop Surg. 2020 Apr 15;28(8):309-315. doi: 10.5435/JAAOS-D-18-00193. PMID: 31851021.
  34. ↑ Zhu H, Li X, Zheng X. A Descriptive Study of Open Fractures Contaminated by Seawater: Infection, Pathogens, and Antibiotic Resistance. Biomed Res Int. 2017;2017:2796054. doi: 10.1155/2017/2796054. Epub 2017 Feb 20. PMID: 28303249; PMCID: PMC5337837.
  35. ↑ https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/humeral-shaft/simple-fracture-transverse-less-than30/external-fixation#patient-preparation-and-approach
  36. ↑ Federal Aviation Administration. Code of Federal Regulations - Sec. 121.542 - Part 121 Operating Requirements: Domestic, flag, and Supplemental Operations. [Internet]. Washington (DC): Federal Aviation Administration; 2014 Feb 2 [cited 2021 Aug 17]. Available from: https://rgl.faa.gov/Regulatory_and_Guidance_Library/rgFAR.nsf/0/7027DA4135C34E2086257CBA004BF853?OpenDocument.
  37. ↑ Cross WW 3rd, Swiontkowski MF. Treatment principles in the management of open fractures. Indian J Orthop. 2008 Oct;42(4):377-86. doi: 10.4103/0019-5413.43373. PMID: 19753224; PMCID: PMC2740354.
  38. ↑ 38.0 38.1 Höntzsch D. Modular External Fixation, 2. Pin Insertion [Internet]. AO Foundation Surgery Reference. AO Foundation Surgery Reference; 2021 [cited 2021 Nov 28]. Available from: https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/basic-technique/basic-technique-modular-external-fixation#pin-insertion.
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Part of Humeral Fracture Fixation
Keywords orthopedic surgery, simulation training, modular external fixation, schanz screws, open humeral fracture, 3d printing, artificial bones
SDG SDG03 Good health and well-being
Authors Medical Makers
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Created July 16, 2022 by Medical Makers
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Cite as Medical Makers (2022–2024). "Modular External Fixation for an Open Humeral Shaft Transverse Fracture". Appropedia. Retrieved April 26, 2024.
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