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Medical course data
Parent Tibial Fracture Fixation/Knowledge Review
Required
time
2 hours

Modular External Fixation for an Open Tibial Shaft Transverse Fracture

This module allows medical officers and surgeons who are not orthopedic specialists to become confident and competent in irrigation and debridement, powered and manual drilling, positioning and correctly inserting Schanz screws, and constructing the rod-to-rod modular frame as part of external fixation procedures for open tibial shaft fractures performed in regions without specialist coverage.

Learning Objectives[edit | edit source]

By the end of this module, learners will be able to:

  1. Provide follow-up care for a patient following modular external fixation of an open tibial shaft fracture.
  2. Review the follow-up anteroposterior and lateral view radiographs of a patient following modular external fixation of an open tibial shaft fracture.
  3. Know how to perform the application of a long leg Plaster of Paris cast and a patellar tendon-bearing (weight-bearing) cast for a tibial shaft fracture.
  4. Know how to perform the application of a long leg Plaster of Paris cast and a patellar tendon-bearing (weight-bearing) cast for a tibial shaft fracture.
  5. Understand this module's training content on the application of a long leg Plaster of Paris cast and a patellar tendon-bearing (weight-bearing) cast for a tibial shaft fracture and can demonstrate it to others.
  6. Verbally explain the objectives and principles of the application of a long leg Plaster of Paris cast and a patellar tendon-bearing (weight-bearing) cast for a tibial shaft fracture.
  7. Verbally explain the sequence and interrelationship between each procedural step of the application of a long leg Plaster of Paris cast and a patellar tendon-bearing (weight-bearing) cast of a tibial shaft fracture.
  8. Precisely imitate the instructed steps and actions of the application of a long leg Plaster of Paris cast and a patellar tendon-bearing (weight-bearing) cast of a tibial shaft fracture.
  9. Smoothly complete the procedure steps of the application of a long leg Plaster of Paris cast and a patellar tendon-bearing (weight-bearing) cast of a tibial shaft fracture.
  10. Monitor their application of a long leg Plaster of Paris cast and a patellar tendon-bearing (weight-bearing) cast of a tibial shaft fracture for improvements.
  11. Monitor their application of a long leg Plaster of Paris cast and a patellar tendon-bearing (weight-bearing) cast of a tibial shaft fracture procedures and make proper adjustments as needed
  12. Identify, report, and monitor adverse events.
It's highly recommended to print off this module, bring it to clinic, and keep it filed in the patient's chart to use as a checklist during the follow-up care of a patient with an open tibial shaft fracture.

Follow-Up Clinical Assessment[edit | edit source]

The purpose of modular external fixation is to provide wound care of an open fracture before definitive fracture care.

Photo Documentation of Injured Extremity[edit | edit source]

Take images of the soft tissue wound(s) of the injured extremity including the joint above and below for orientation and with a ruler included for scale to assess healing progress and for comparison for subsequent follow-up visits.

Wound Infection[edit | edit source]

Signs of wound infection are: (i) local erythema; (ii) swelling; (iii) tenderness; (iv) purulent discharge.

  • Infected
    • Date of Diagnosis: ___________________
  • Not Infected
If there are signs of soft tissue infection, increase the frequency of wound cleaning and dressing changes to twice a day. Obtain > 3 tissue specimens with clean instruments (not superficial or sinus tract swabs) for wound cultures to confirm the diagnosis of infection and guide antibiotic selection.[1]

Wound Healing[edit | edit source]

Check that wound is well granulated by looking for velvety red tissue in the wound bed.

  • Healing
  • Not Healing
If there is no progress in wound healing at the follow-up visit at 6 weeks, the patient should be referred to a tertiary center for specialist care.

Wound Status[edit | edit source]

Skin coverage of soft tissue wounds usually occurs at 2 to 4 weeks.

  • Healed
  • Unhealed

Pin Site Infection[edit | edit source]

Pin site infections are not considered surgical site infections.[2]

Signs of pin site infection are: (i) local erythema, (ii) swelling, (iii) tenderness, and (iv) purulent discharge.

  • Pin Site Infection
    • Proximal Fragment
      • Schanz Screw #1 (Far Pin)
      • Schanz Screw #2 (Near Pin)
    • Distal Fragment
      • Schanz Screw #3 (Near Pin)
      • Schanz Screw #4 (Far Pin)
    • Date of Diagnosis: ___________________
  • No Pin Site Infection
If a pin site infection is present, the pin site should be cleaned daily. If the infection persists leading to pin loosening, the pin should be removed in the operating room, and > two deep tissue specimens (i.e., pin tract curettes) are taken to obtain wound cultures.[1]

Fracture-Related Infection[edit | edit source]

The confirmatory criteria for a fracture-related infection are: (i) fistula, sinus or wound breakdown (with communication to the bone or the implant); and/or (ii) purulent drainage from the wound or presence of pus during surgery.[1]

  • Fracture-Related Infection
    • Date of Diagnosis: ___________________
  • No Fracture-Related Infection
If there are clinical signs of fracture-related infection, the patient should be referred to a tertiary center for specialist care.[1]

Pin Loosening[edit | edit source]

Signs of pin loosening are: (i) pain around the pin site and (ii) seropurulent discharge from the pin site.[3]

If these signs are present, loosen the pin-to-rod clamp and evaluate if the pin can be freely turned by hand. Normally, a pin cannot be turned by hand.

  • Pin Loosening
    • Proximal Fragment
      • Schanz Screw #1 (Far Pin)
      • Schanz Screw #2 (Near Pin)
    • Distal Fragment
      • Schanz Screw #3 (Near Pin)
      • Schanz Screw #4 (Far Pin)
    • Date of Diagnosis: ___________________
  • No Pin Loosening
If pin loosening occurs, the pin should be removed in the operating room and a new pin inserted 2.0 cm from the original pin site.

Pin Failure[edit | edit source]

  • Broken Pins
    • Proximal Fragment
      • Schanz Screw #1 (Far Pin)
      • Schanz Screw #2 (Near Pin)
    • Distal Fragment
      • Schanz Screw #3 (Near Pin)
      • Schanz Screw #4 (Far Pin)
    • Date of Diagnosis: ___________________
  • No Broken Pins
If pin failure occurs, the pin should be removed in the operating room and a new pin inserted 2.0 cm from the original pin site.

Frame Loosening[edit | edit source]

Check that all the clamps are securely tightened. Use the 11 mm spanner with T handle to tighten clamps in the clinic, if required.

  • Proximal Fragment Rod
    • Schanz Screw #1 (Far Pin) Clamp
    • Schanz Screw #2 (Near Pin) Clamp
  • Connecting Rod
    • Proximal Rod-to-Rod Clamp
    • Distal Rod-to-Rod Clamp
  • Distal Fragment Rod
    • Schanz Screw #3 (Near Pin) Clamp
    • Schanz Screw #4 (Far Pin) Clamp

Frame Component Failure[edit | edit source]

  • Frame Component Failure
    • Schanz Screw #1 (Far Pin) Clamp
    • Proximal Fragment Rod
    • Schanz Screw #2 (Near Pin) Clamp
    • Proximal Rod-to-Rod Clamp
    • Connecting Rod
    • Distal Rod-to-Rod Clamp
    • Schanz Screw #3 (Near Pin) Clamp
    • Distal Fragment Rod
    • Schanz Screw #4 (Far Pin) Clamp
    • Date of Diagnosis: ___________________
  • No Frame Component Failure
If a frame component fails, replace the component in clinic and notify the hardware manufacturer.

Musculoskeletal Exam[edit | edit source]

If patient cannot perform active range of motion, then test passive range of motion of the knee and ankle joints. Compare both sides.

Knee Flexion

  • Active Range of Motion
  • Passive Range of Motion Only
  • Normal (135°)
  • Abnormal: ________°
  • Symmetric versus Asymmetric

Knee Extension

  • Active Range of Motion
  • Passive Range of Motion Only
  • Normal (0°)
  • Abnormal: ________°
  • Symmetric versus Asymmetric

Ankle Dorsiflexion

  • Active Range of Motion
  • Passive Range of Motion Only
  • Normal (20°)
  • Abnormal: ________°
  • Symmetric versus Asymmetric_

Ankle Plantarflexion

  • Active Range of Motion
  • Passive Range of Motion Only
  • Normal (50°)
  • Abnormal: ________°
  • Symmetric versus Asymmetric
If reduced or abnormal range of motion is observed, refer patient to a physical therapist.

Follow-Up Radiographic Findings[edit | edit source]

Obtain anteroposterior (AP) and lateral view radiographs at 4 weeks post-discharge and each subsequent follow-up visit.

Maintenance of Reduction[edit | edit source]

The acceptable parameters for a reduced tibial fracture are: (i) > 50% bone apposition;[4] and (ii) < 10 degrees of angulation in any plane.[2][5][6]

Angulation can be assessed in the coronal or sagittal plane. The AP view shows the coronal plane and the lateral view shows the sagittal plane.

  • Tibial Fracture Reduction Maintained
    • > 50% Bone Apposition;[4] and
    • < 10 Degrees of Angulation in any Plane[2][5][6]
  • Tibial Fracture Reduction Not Maintained
    • < 50% Bone Apposition; or
    • > 10 Degrees of Angulation in any Plane
If reduction is not maintained, check for hardware loosening and ensure hardware is securely tightened.
There is no evidence-based consensus on how much variation from anatomic alignment is acceptable to achieve an adequate functional outcome.[7][8] Malalignment identified during initial follow-up can be corrected during definitive treatment with plaster of Paris casting or internal fixation. 

Modified Radiographic Union Scale for Tibia Fractures (mRUST) Score[edit | edit source]

Anteroposterior View

  • Near Cortex
    • 1 - No Callus
    • 2 - Callus Present
    • 3 - Bridging Callus
    • 4 - Remodeled, fracture not visible
  • Far Cortex
    • 1 - No Callus
    • 2 - Callus Present
    • 3 - Bridging Callus
    • 4 - Remodeled, fracture not visible

Lateral View

  • Near Cortex
    • 1 - No Callus
    • 2 - Callus Present
    • 3 - Bridging Callus
    • 4 - Remodeled, fracture not visible
  • Far Cortex
    • 1 - No Callus
    • 2 - Callus Present
    • 3 - Bridging Callus
    • 4 - Remodeled, fracture not visible

Total mRUST Score (4-16):[2][9] _______________

Tibial Fracture Healed Radiographically

  • Yes (Total mRUST Score > 11)
  • No (Total mRUST Score < 11)

Malalignment[edit | edit source]

Malalignment is defined by one or more of the following features: (i) < 50% bone apposition; (ii) >10 degrees of angulation in any plane; (iii) > 10 degrees of rotation; (iv) > 2 cm length shortening; (v) any distraction.[2][4][5][10][11][12]

  • Malalignment
    • Date of Diagnosis: ___________________
  • No Malalignment
If malalignment is not corrected at the time of definitive treatment, refer patient to a tertiary center for specialist care.

Malunion[edit | edit source]

Malunion is when a fracture heals with a deformity that causes cosmetic or functional impairment (shortening, angulation, or rotational deformities) and is defined by one or more of the following features: (i) leg length discrepancy (> 2 cm shortening); or (ii) angular malalignment (> 10 degrees of angulation in any plane); or (iii) malrotation (> 10 degrees).[2][4][6][5][11][12][13]

  • Malunion
    • Date of Diagnosis: ___________________
  • No Malunion
If malunion occurs in a healed fracture, refer patient to a tertiary center for specialist care.

Delayed Union[edit | edit source]

Delayed union is diagnosed when the fracture unites between 4-6 months.

  • Delayed Union
    • Date of Diagnosis: ___________________
  • No Delayed Union
If union is delayed at 4 months, refer patient to a tertiary center for specialist care.

Nonunion[edit | edit source]

A nonunion is defined as: (i) an mRUST score of <10 at or after the 6-month follow-up visit; or (ii) failure of the fracture to heal beyond 6 months from the date of injury.[2][13][14]

  • Nonunion
    • Date of Diagnosis: ___________________
  • No Nonunion
If nonunion occurs, refer patient to a tertiary center for specialist care.

Pin Failure[edit | edit source]

Check for broken pins on the radiographs.

  • Broken Pins
    • Proximal Fragment
      • Schanz Screw #1 (Far Pin)
      • Schanz Screw #2 (Near Pin)
    • Distal Fragment
      • Schanz Screw #1 (Far Pin)
      • Schanz Screw #2 (Near Pin)
    • Date of Diagnosis: ___________________
  • No Broken Pins
If pin failure occurs, the pin should be removed in the operating room and a new pin inserted 2.0 cm from the original pin site.

Pin Site Fracture[edit | edit source]

  • Pin Site Fracture
    • Proximal Fragment
      • Schanz Screw #1 (Far Pin)
      • Schanz Screw #2 (Near Pin)
    • Distal Fragment
      • Schanz Screw #1 (Far Pin)
      • Schanz Screw #2 (Near Pin)
    • Date of Diagnosis: ___________________
  • No Pin Site Fracture
If a fracture around a pin occurs, refer patient to a tertiary center for specialist care.

Osteonecrosis[edit | edit source]

Osteonecrosis is defined as in situ death of bone tissue due to loss of blood supply. The primary symptom of osteonecrosis is pain. It can be seen on X-ray as a ring sequestrate (Figure A) encircling the implant.[15][16]

  • Osteonecrosis
    • Date of Diagnosis: ___________________
  • No Osteonecrosis
If signs of osteonecrosis are present, refer patient to a tertiary center for specialist care.

Other Imaging Findings[edit | edit source]

Note other clinically significant radiographic findings.

Complications[edit | edit source]

Adverse events will be identified, reported, and monitored.

Potential complications include but are not limited to:

  • Wound Infection
  • Delayed Wound Healing
  • Pin Site Infection
  • Fracture-Related Infection
  • Pin Loosening
  • Pin Failure
  • Frame Component Failure
  • Malalignment
  • Malunion
  • Nonunion
  • Pin Site Fracture
  • Osteonecrosis
  • Muscle/Tendon Fibrosis
  • Deep Venous Thrombosis / Pulmonary Embolism
  • Tetanus
  • Pressure Injury (also known as a pressure sore or decubitus ulcer)
  • Gangrene
  • Sepsis
  • Shock
  • Death
  • Other: _______________________

Functional Assessment After Cast Removal[edit | edit source]

After cast removal, assess the patient's functional status:

History

  • Pain, tenderness or abnormal motion at fracture site
  • Able to return to normal work activities

Physical Examination

  • Observe if patient can squat and smile

Follow-up Care Plan[edit | edit source]

Visit Schedule[edit | edit source]

Patients should be followed up in the clinic at 2 weeks, 4 weeks, 6 weeks, 8 weeks, 12 weeks, 6 months, and 1 year.

Physical Therapy[edit | edit source]

Encourage continuous active range of motion exercises for knee, ankle and toe joints to prevent stiffness.

Wound Coverage[edit | edit source]

Definitive wound coverage options include:

  • Primary Intention (Suture Closure)
  • Secondary Intention
  • Tertiary Intention (Delayed Wound Closure)
    • Suture Closure
    • Skin Graft
    • Local Flap
    • Distal Flap
    • Free Flap
    • Other: __________________________________

Definitive Treatment Options[edit | edit source]

After wound healing and removal of modular external fixation, the definitive treatment options are:

  1. Plaster of Paris Cast; or
  2. Internal Fixation

Long Leg Plaster of Paris Cast Treatment[edit | edit source]

Once all soft tissue injuries have healed with skin coverage (usually at 2 to 4 weeks):

  1. the modular external fixator will be removed in the clinic,
  2. the pin insertion sites will be covered with sterile gauze, and
  3. a long leg Plaster of Paris cast will be applied by the physician or orthopedic cast technician.

Please review the following learning resources:

Patellar Tendon-Bearing Cast[edit | edit source]

After application of the long leg Plaster of Paris cast, the patient will be kept non-weight-bearing and be converted to a patellar tendon-bearing (weight-bearing) cast by the physician or orthopedic cast technician after a minimum of 8 weeks post-injury and maximum of 3 months on the basis of the radiographic appearance of the fracture callus.

The patellar tendon-bearing (weight-bearing) cast is worn for a minimum of 4 weeks on the basis of the radiographic appearance of the fracture callus, patient age, and other clinical factors.[17]

Please review the following learning resource:

Definitive Internal Fixation[edit | edit source]

After removal of the modular external fixator, patients may opt for definitive internal fixation with intramedullary nailing or plate fixation for faster recovery times instead of casting if orthopedic surgical expertise is locally available.

Need for Referral To A Tertiary Center for Specialist Care[edit | edit source]

  • Referral To A Tertiary Center for Specialist Care
    • Specialty Consulted: ___________________
    • Reason for Referral
      • Delayed Wound Healing
      • Fracture-Related Infection
      • Malalignment
      • Malunion
      • Delayed Union
      • Nonunion
      • Pin Site Fracture
      • Osteonecrosis
      • Advanced Wound Coverage Techniques
      • Limb Amputation
      • Other: ___________________
    • Date of Referral: ___________________
  • No Referral To A Tertiary Center for Specialist Care

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 1.2 1.3 Metsemakers WJ, Morgenstern M, McNally MA, Moriarty TF, McFadyen I, Scarborough M, Athanasou NA, Ochsner PE, Kuehl R, Raschke M, Borens O, Xie Z, Velkes S, Hungerer S, Kates SL, Zalavras C, Giannoudis PV, Richards, RG, Verhofstad MHJ. Fracture-related infection: A consensus on definition from an international expert group. Injury. 2018 Mar;49(3):505-510. doi:10.1016/j.injury.2017.08.040. Epub 2017 Aug 24. PMID: 28867644.
  2. 2.0 2.1 2.2 2.3 2.4 2.5 2.6 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.
  3. 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.
  4. 4.0 4.1 4.2 4.3 https://www.orthobullets.com/trauma/1045/tibial-shaft-fractures
  5. 5.0 5.1 5.2 5.3 Nicoll EA. Fractures of the tibial shaft. A survey of 705 cases. J Bone Joint Surg Br. 1964 Aug;46:373-87.
  6. 6.0 6.1 6.2 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.
  7. Schmidt AH, Finkemeier CG, Tornetta P 3rd. Treatment of closed tibial fractures. Instr Course Lect. 2003;52:607-22. PMID: 12690886.
  8. Milner SA. A more accurate method of measurement of angulation after fractures of the tibia. J Bone Joint Surg Br. 1997 Nov;79(6):972-4. doi: 10.1302/0301-620x.79b6.7458. PMID: 9393915.
  9. Litrenta J, Tornetta P 3rd, Mehta S, Jones C, OʼToole RV, Bhandari M, Kottmeier S, Ostrum R, Egol K, Ricci W, Schemitsch E, Horwitz D. Determination of Radiographic Healing: An Assessment of Consistency Using RUST and Modified RUST in Metadiaphyseal Fractures. J Orthop Trauma. 2015 Nov;29(11):516-20. doi: 10.1097/BOT.0000000000000390. PMID: 26165265.
  10. https://www.wheelessonline.com/bones/x-rays-for-tibial-frx/
  11. 11.0 11.1 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.
  12. 12.0 12.1 Puno RM, Vaughan JJ, Stetten ML, Johnson JR. Long-term effects of tibial angular malunion on the knee and ankle joints. J Orthop Trauma. 1991;5(3):247-54.
  13. 13.0 13.1 Ibrahim J, Liu M, Yusi K, Haonga B, Eliezer E, Shearer DW, Morshed S. Conducting a Randomized Controlled Trial in Tanzania: Institute for Global Orthopaedics and Traumatology and the Muhimbili Orthopaedic Institute. J Orthop Trauma. 2018 Oct;32 Suppl 7:S47-S51. doi: 10.1097/BOT.0000000000001294. PMID: 30247401.
  14. Litrenta J, Tornetta P 3rd, Mehta S, Jones C, OʼToole RV, Bhandari M, Kottmeier S, Ostrum R, Egol K, Ricci W, Schemitsch E, Horwitz D. Determination of radiographic healing: an assessment of consistency using RUST and modified RUST in meta-diaphyseal fractures. J Orthop Trauma. 2015 Nov;29(11):516-20.
  15. National Institute of Arthritis and Musculoskeletal and Skin Disease. Osteonecrosis. https://www.niams.nih.gov/health-topics/osteonecrosis/advanced 2015.
  16. 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.
  17. https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/tibial-shaft/simple-fracture-transverse/nonoperative-casting#sarmiento-or-ptb-patella-tendon-bearing-cast.
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Published 2022
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