Medical skill data
Required time 1 hour 3D Printed Adult Male Tibial Bone ModelsArbutus Medical HEX Drill KitTibial Shaft Transverse Fracture Simulator

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 tibial 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.

## Learning Objectives

### Training Objectives

By the end of this module, learners will be able to perform the following procedural steps:

1. Perform irrigation using an average of 3L of irrigation solution for each successive Gustilo Type (i.e., 6L for Gustilo Type II open tibial fracture and 9L for Gustilo Type III open tibial 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. 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.[5][6]

4. Position the “far” Schanz screw (furthest from the fracture line) in the proximal fragment medial or distal to the tibial tuberosity while avoiding traumatized soft tissues to avoid tethering of the patellar ligament and penetration into the knee joint.[7]

5. Place the "far" Schanz screw in the distal fragment at least two fingers’ breadth proximal to the medial malleolus while avoiding traumatized soft tissues to avoid entry into the ankle joint.*

6. Position the "near and far" Schanz screws as widely apart as possible into each fragment while avoiding traumatized soft tissues and entry into knee and ankle joints to permit better control of displacing forces and optimize stabilization of the reduction.[6][8][9][10]

7. Use a scalpel to make a stab incision into the soft tissue overlying the anteromedial wall of the tibia for each Schanz screw.*[11]

8. Use dissecting scissors to spread the soft tissue apart in each stab incision to expose the bone for drilling.*

9. 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.

10. 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.

11. Use the properly sized drill sleeve for the Schanz screws.

12. Place the drill sleeve directly on the near cortex in each stab incision to protect the surrounding soft tissues when drilling.*[11]

13. Place each Schanz screw tip directly on the near cortex of the anteromedial tibial wall and not on the anterior tibial crest.

14. Apply the correct drill trajectory angles for proper insertion of the Schanz screws into the safe zones of the tibia to reduce the risk of damage to neurovascular structures:

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

16. Place the Schanz screw tip on the anteromedial tibial wall, 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 medial and lateral soft tissues.[11][12]

17. Power drill each Schanz screw through the near cortex of the anteromedial tibial wall 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.[11][15]

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

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

20. Use the universal chuck with T-handle to turn each Schanz screw manually for one to two 360 degree rotations to anchor the screw tip into the far cortex without exiting the far cortex.

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

22. Apply the pin-to-rod clamps to connect the two Schanz screws in each main fragment to a 250 mm rod.[11]

23. 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.

24. Apply the rod-to-rod clamps to loosely fix the 200 mm connecting rod to interconnect the two 250 mm rods for the proximal and distal fragments.

25. Use the two 250 mm rods as handles to manually reduce the fracture and restore alignment.

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

27. 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 200 mm connecting rod.

28. Verify the reduction visually, and with gentle palpation of the tibial crest at the fracture line to confirm whether the alignment is within acceptable parameters.

29. Confirm restoration of rotational alignment by visually checking the position of the big toe and the alignment of the middle of the second toe with the center of the patella.*[16]

30. Palpate the medial malleolus of both limbs under sterile conditions to estimate and compare the length of the reduced limb to the uninjured limb.*[17]

• Bone apposition > 50%[18]
• Rotation < 10 degrees[18][19][20]
• Angulation < 10 degrees in any plane[19][21][22]
• Length discrepancy < 2 cm shortening[19]
• No distraction (lengthening)[20]

32. 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.*[23]

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

34. Use a measuring tape to measure and compare the limb length (from the anterior superior iliac spine to the medial malleolus) of both legs to confirm acceptable length discrepancy in the injured leg after dressings have been applied.*[17]

35. 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][24][25][26][27][28]

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


### Knowledge Objectives

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

1. Irrigate a Gustilo Type II open tibial 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.

2. Debride all foreign material and non-viable tissue to reduce the risk of infection and minimize wound complications.

3. Position the far Schanz screw in the distal fragment at least two fingers’ breadth proximal to the medial malleolus while avoiding traumatized soft tissues to avoid penetration into the ankle joint.

4. Use a scalpel to make a stab incision in the soft tissue overlying the anteromedial tibial wall for each Schanz screw.[11]

5. Used dissecting scissors to spread the soft tissue in each stab incision to expose the bone for drilling.

6. Place the drill sleeve directly on the cortex in each stab incision to protect the surrounding soft tissues when drilling.

7. Direct an assistant to provide irrigation while drilling is performed to reduce the risk of thermal osteonecrosis.[14]

8. Confirm restoration of rotational alignment by visually checking the position of the big toe and the alignment of the middle of the second toe with the center of patella.

9. Palpate the medial malleolus of both limbs under sterile conditions to estimate and compare the length of the reduced limb to the uninjured limb to confirm acceptable length discrepancy in the injured leg.

10. 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.

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

12. Use a measuring tape to measure and compare the limb length (from the anterior superior iliac spine to the medial malleolus) of both legs to confirm acceptable length discrepancy in the injured leg after dressings have been applied.

13. 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.

## Materials and Equipment

1
Modular External Fixation Hardware Courtesy of Medical Aid International and Dr. Habila Umaru
Modular External Fixation Hardware
• 5.0 mm drill sleeve
• Self-drilling Schanz screws, 5.0 mm diameter, Quantity: 4
• 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
• 250 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
• 200 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
Surgical Supplies
• Eye protection
• Gloves
• 50 mL syringe*
• Scalpel handle with 22 blade*
• Dissecting scissors*
• Any powered surgical drill compatible with 5.0 mm diameter Schanz screws
• Chuck key
• Measuring tape*
The items above highlighted with an asterix (*) are not used in this simulation training but are used during the actual clinical procedure.

3
Tibial Shaft Transverse Fracture Simulator Secured In Vise Clamps
Tibial Shaft Transverse Fracture Simulator
The vise clamps securing the Tibial 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
Self-Assessment Framework Supplies
• Scissors
• Ruler
• Protractor
• Clipboard
• Training Logbook
• Pen
• Any cellphone with a camera

## Procedure Steps

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.[29]

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.

2. Wear proper eye protection and gloves.

3. 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 tibial 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.

4. Normally, all foreign material and non-viable tissue is debrided to reduce the risk of infection and minimize wound complications.[3][4][30] However, the simulator does not display foreign material or non-viable tissue so this step is skipped during this simulation training.
2
While avoiding traumatized soft tissues, (i) place the two near pins at least 2.0 cm from the fracture line, (ii) position the far pin in the proximal fragment medial or distal to the tibial tuberosity, (iii) place the far pin in the distal fragment at least two fingers’ breadth proximal to the medial malleolus, and (iv) position the near and far pins as widely spaced as possible into each fragment while avoiding entry into knee and ankle joints.
Place Two Schanz Screws In Each Fragment

1. 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.*[5][6] This helps prevent the placement of the Schanz screw within the fracture hematoma and risk having a pin site infection spread within the fracture.

2. Position the “far” Schanz screw (furthest from the fracture line) in the proximal fragment medial or distal to the tibial tuberosity while avoiding traumatized soft tissues.* Inserting the Schanz screw medial or distal to the tibial tuberosity avoids tethering of the patellar ligament and penetration into the knee joint.[7]

3. Normally, the "far" Schanz screw in the distal fragment should be placed at least two fingers’ breadth proximal to the medial malleolus while avoiding traumatized soft tissues to avoid entry into the ankle joint.* However, the simulator does not display the medial malleolus so this step is skipped during this simulation training.

4. Position the “near and far” Schanz screws as widely spaced as possible into each fragment while avoiding traumatized soft tissues, and entry into knee and ankle joints.* The wide placement of near and far Schanz screws in each fragment permits better control of displacing forces and optimizes stabilization of the reduction.[6][8][9][10]

5. Normally, a 22 blade scalpel is used to make a stab incision in the soft tissue overlying the anteromedial tibial wall for each Schanz screw.[11] However, the simulator does not have simulated soft tissue so this step is skipped during this simulation training.

6. Normally, dissecting scissors are used to spread the soft tissue apart in each stab incision to expose the bone for drilling. However, the simulator does not have simulated soft tissue so this step is skipped during this simulation training.
3
Normally, the drill sleeve is positioned directly on the cortex in each stab incision to protect the surrounding soft tissues when drilling.[11] 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.
Insert Schanz Screws Into Safe Zones of the Tibia

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. 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. Slide the 5.0 mm drill sleeve over the 5.0 mm diameter Schanz screw. 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. Normally, the drill sleeve is positioned directly on the cortex in each stab incision to protect the surrounding soft tissues when drilling.[11] 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.

7. Place each Schanz screw tip directly on the near cortex of the anteromedial tibial wall. Inserting Schanz screws into the thick anterior tibial crest is not recommended because the screw tip can slip medially or laterally and injure soft tissue.[5]

8. Insert the near and far Schanz screws in the proximal fragment at a drill trajectory angle between 20°-60° relative to the tibial crest to reduce the risk of damage to neurovascular structures.*[12][13]

9. Insert the near and far Schanz screws in the distal fragment at a drill trajectory angle between 30°-90° relative to the tibial crest to reduce the risk of damage to neurovascular structures.*
You can insert all four Schanz screws at a drill trajectory angle between 30°-60° for the proximal and distal fragments of an open tibial shaft fracture.

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.[14] 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 anteromedial tibial wall, 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 anteromedial tibial wall. 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.

5. Insert the chuck key into the opening in the drill, turn the chuck key anticlockwise, and detach the drill from the Schanz screw.

6. Remove the drill sleeve from the Schanz screw.
5
Manually Advance Schanz Screws Into Far Cortex
The protruding tip of the self-drilling Schanz screw can injure the underlying soft tissue.[31] 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 anticlockwise, or (ii) insert the chuck key into the opening in the chuck and turn the chuck key clockwise.

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.*[31] Resistance can be felt when the Schanz screw is being anchored into the inner side of the far cortex.

4. 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.

5. To detach the chuck from each Schanz screw, (i) manually rotate the proximal part of the chuck clockwise, or (ii) insert the chuck key into the opening in the chuck and turn the chuck key anticlockwise.

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 250 mm rod.[11]

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 200 mm connecting rod to interconnect the 250 mm rods for the proximal and distal fragments.

8
Use Rods and Schanz Screws to Reduce and Compress Fracture

1. Loosen the right vise clamp securing the distal fragment to simulate a displaced fracture.

2. Use the two 250 mm rods as handles to manually reduce the fracture and restore alignment

• Bone apposition > 50%
• Angulation < 10 degrees in any plane
• Rotation < 10 degrees*

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

• Length discrepancy < 2 cm shortening
• No distraction (lengthening)*
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 200 mm connecting rod.*

2. Verify the reduction visually, and with gentle palpation of the tibial crest at the fracture line to confirm whether the alignment is within acceptable parameters

• Bone apposition > 50%
• Rotation < 10 degrees

Normally, restoration of rotational alignment is confirmed by visually checking the position of the big toe and the alignment of the middle of the second toe with the center of patella.[16] However, the simulator does not include a foot or patella so the tibial crest will be visually inspected and palpated to verify restoration of rotational alignment during this simulation training.

At 0 degrees of rotation, the big toe is pointing straight up towards the ceiling and the middle of the second toe is aligned with the center of the patella. If the distal lower extremity is rotated > 10 degrees, it should be described as externally or internally rotated. External rotation is when the foot is turned outward (outtoeing) and internal rotation is when the foot is turned inwards (intoeing).


3. Visually inspect the fracture line to confirm that the reduction is adequate

• Length discrepancy < 2 cm shortening
• No distraction (lengthening)

Normally, the medial malleolus of both limbs is palpated under sterile conditions to estimate and compare the length of the reduced limb to the uninjured limb. Then a measuring tape is used to measure and compare the limb length (from the anterior superior iliac spine to the medial malleolus) of both legs to confirm acceptable length discrepancy in the injured leg after dressings have been applied.[17] However, the simulator does not display the contralateral limb, anterior superior iliac spine or medial malleolus so the fracture line will be visually inspected for shortening or distraction to confirm that the fracture has been adequately reduced during this simulation training.

• Bone apposition > 50%
• Rotation < 10 degrees
• Angulation < 10 degrees in any plane
• Length discrepancy < 2 cm shortening
• No distraction (lengthening)*

5. 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.[23] However, the simulator does not have simulated soft tissue so this step is skipped during this simulation training.
10
Normally, a measuring tape should be used to measure and compare the limb length (from the anterior superior iliac spine to the medial malleolus) of both legs to confirm acceptable length discrepancy in the injured leg after dressings have been applied.[17]
Apply Dressing and Evaluate Extremity

1. 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.

2. Normally, a measuring tape should be used to measure and compare the limb length (from the anterior superior iliac spine to the medial malleolus) of both legs to confirm acceptable length discrepancy in the injured leg after dressings have been applied.[17] However, the simulator does not display the contralateral limb or anterior superior iliac spine so 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.[24][25][26][27] 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

 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.
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

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

Once the self-assessment framework has been completed:

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

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

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. https://www.orthobullets.com/trauma/1004/open-fractures-management
5. 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.
6. Giotakis N, Narayan B. Stability with unilateral external fixation in the tibia. Strategies Trauma Limb Reconstr. 2007 Apr;2(1):13-20. doi: 10.1007/s11751-007-0011-y. PMID: 18427910; PMCID: PMC2321723.
7. Nayagam S. Safe corridors in external fixation: the lower leg (tibia, fibula, hindfoot and forefoot). Strategies Trauma Limb Reconstr. 2007 Dec;2(2-3):105-10. doi: 10.1007/s11751-007-0023-7. Epub 2007 Dec 4. PMID: 18427752; PMCID: PMC2322836.
9. Briggs BT, Chao EY (1982) The mechanical performance of the standard Hoffmann-Vidal external fixation apparatus. J Bone Joint Surg Am 64:566–573.
10. Huiskes R, Chao E (1986) Guidelines for external fixation frame rigidity and stresses. J Orthop Res 4:68–75.
11. 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.
13. Höntzsch D. Safe Zones In The Tibia for 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/tibial-shaft/approach/safe-zones-of-the-tibia-for-pin-insertion.
14. 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.
15. 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/.
16. 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.
17. Sabharwal S, Kumar A. Methods for assessing leg length discrepancy. Clin Orthop Relat Res. 2008 Dec;466(12):2910-22. doi: 10.1007/s11999-008-0524-9. Epub 2008 Oct 4. PMID: 18836788; PMCID: PMC2628227.
18. https://www.orthobullets.com/trauma/1045/tibial-shaft-fractures
19. Nicoll EA. Fractures of the tibial shaft. A survey of 705 cases. J Bone Joint Surg Br. 1964 Aug;46:373-87.
20. https://www.wheelessonline.com/bones/x-rays-for-tibial-frx/
21. Haonga BT, Liu M, Albright P, Challa ST, Ali SH, Lazar AA, Eliezer EN, Shearer DW, Morshed S. Intramedullary Nailing Versus External Fixation in the Treatment of Open Tibial Fractures in Tanzania: Results of a Randomized Clinical Trial. J Bone Joint Surg Am. 2020 May 20;102(10):896-905. doi: 10.2106/JBJS.19.00563. PMID: 32028315; PMCID: PMC7508278.
22. Merchant TC, Dietz FR. Long-term follow-up after fractures of the tibial and fibular shafts. J Bone Joint Surg Am. 1989 Apr;71(4):599-606. PMID: 2703519.