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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. Conduct a history and physical examination of a patient following modular external fixation of an open tibial shaft fracture.
  2. Review the post-operative anteroposterior and lateral view radiographs of a patient following modular external fixation of an open tibial shaft fracture.
  3. Provide post-operative care for a patient following modular external fixation of an open tibial shaft fracture.
  4. Know the indications for adjusting the modular external fixator for a patient with an open, simple tibial shaft fracture.
  5. Know the indications for referral of a patient with an open tibial shaft fracture to a tertiary center for specialist care.
It's highly recommended to print off this module, bring it on ward rounds, have it available when reviewing the patient's X-rays, and keep it filed in the patient's chart to use as a checklist during the post-operative management of a patient with an open tibial shaft fracture.

Postoperative Clinical Assessment[edit | edit source]

Neurovascular Exam[edit | edit source]

Vascular Exam[edit | edit source]

Compare both sides when evaluating dorsalis pedis artery pulses.

  • Palpable versus Not Palpable
  • Symmetric versus Asymmetric

If dorsalis pedis artery pulses are not palpable, check for posterior tibial artery pulses.

If posterior tibial artery pulses are not palpable, check for signs of acute compartment syndrome.

Sensory Testing[edit | edit source]

To test the lateral dorsal cutaneous branch of the sural nerve (S1-2), perform light touch sensation testing on the lateral aspect of the little toe and compare it to the other side.

  • Intact versus Not Intact
  • Symmetric versus Asymmetric

To test the deep peroneal nerve (L4-5), perform light touch sensation testing on the first dorsal webspace of the foot and compare it to the other side.

  • Intact versus Not Intact
  • Symmetric versus Asymmetric

To test the superficial peroneal nerve (L4-S1), perform light touch sensation testing on the dorsum of the foot (except the first webspace) and compare it to the other side.

  • Intact versus Not Intact
  • Symmetric versus Asymmetric

Motor Testing[edit | edit source]

Ask patient to perform ankle dorsiflexion for motor testing of the tibialis anterior muscle. Be sure to compare both sides.

  • Able versus Unable
  • Symmetric versus Asymmetric

Ask patient to perform ankle plantar flexion for motor testing of the gastrocnemius and soleus muscles. Be sure to compare both sides.

  • Able versus Unable
  • Symmetric versus Asymmetric

If patient is unable to dorsiflex and plantarflex the ankle, ask the patient to move their toes.

Deep Tendon Reflexes[edit | edit source]

Place your hand under the foot to dorsiflex the ankle and strike the Achilles tendon. Observe for plantar flexion at the ankle and contraction of the calf muscle. Be sure to compare both sides.

Reflex Grading:

  • 0 Absent
  • 1+ Diminished
  • 2+ Normal
  • 3+ Increased
  • 4+ Hyperactive
  • 5+ Sustained clonus
  • Symmetric versus Asymmetric

Acute Compartment Syndrome[edit | edit source]

Evaluate for symptoms of acute compartment syndrome.[1]

  • Pain disproportionate to injury and intensified with passive stretch (i.e., flexion and extension of the toes)
  • Pallor
  • Paresthesias
  • Paralysis
  • Pulselessness
  • Compartment pressure greater than 30-40 mmHg in an unconscious or paralyzed patient
Acute compartment syndrome is a surgical emergency and must be treated with a fasciotomy. If the patient has signs of acute compartment syndrome, the patient should be referred to a tertiary center for specialist care.

Skin Tenting[edit | edit source]

All pin sites will be 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.[2]

  • Proximal Fragment
    • Schanz Screw #1 (Far Pin)
    • Schanz Screw #2 (Near Pin)
  • Distal Fragment
    • Schanz Screw #3 (Near Pin)
    • Schanz Screw #4 (Far Pin)

Patellar Ligament Tethering[edit | edit source]

Look for patellar ligament tethering by checking if: (i) the far Schanz screw in the proximal fragment is placed directly on or proximal to the tibial tuberosity, and (ii) the patient has limited range of motion for knee flexion due to localized pain.

  • Patellar Ligament Tethering
  • No Patellar Ligament Tethering
If there is patellar ligament tethering, the pin must be changed. The patient should return to the operating room for pin re-positioning medial or distal to the tibial tuberosity.

Proper Placement of Far Pin in Distal Fragment[edit | edit source]

Check whether the Schanz Screw #4 (Far Pin) in the distal fragment was placed at least 2 fingers’ breadth proximal to the medial malleolus.

  • Distal Fragment Far Pin Placed At Least 2 Fingers' Breadth Proximal to Medial Malleolus
  • Distal Fragment Far Pin Not Placed At Least 2 Fingers' Breadth Proximal to Medial Malleolus
Always review the post-operative X-ray to check whether the pin has entered the ankle joint.

Drill Trajectory Angles Within Safe Zones of the Tibia[edit | edit source]

Proximal Fragment[edit | edit source]

Use a goniometer to verify that the drill trajectory angle relative to the tibial crest is between 20°-60° for both Schanz screws for the proximal fragment.

  • Drill Trajectory Angle Relative to the Tibial Crest is Between 20°-60°
    • Schanz Screw #1 (Far Pin)
    • Schanz Screw #2 (Near Pin)
  • Drill Trajectory Angle Relative to the Tibial Crest is Not Between 20°-60°
    • Schanz Screw #1 (Far Pin)
    • Schanz Screw #2 (Near Pin)

Distal Fragment[edit | edit source]

Use a goniometer to verify that the drill trajectory angle relative to the tibial crest is between 30°-90° for both Schanz screws for the distal fragment.

  • Drill Trajectory Angle Relative to the Tibial Crest is Between 30°-90°
    • Schanz Screw #3 (Near Pin)
    • Schanz Screw #4 (Far Pin)
  • Drill Trajectory Angle Relative to the Tibial Crest is Not Between 30°-90°
    • Schanz Screw #3 (Near Pin)
    • Schanz Screw #4 (Far Pin)
If any of the drill trajectory angles are outside of the safe zones of the tibia, assess for neurovascular injury.

Frame Loosening[edit | edit source]

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

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

Other Clinical Findings[edit | edit source]

Please describe any other relevant clinical findings.

Post-Operative Radiographic Findings[edit | edit source]

Review postoperative anteroposterior (AP) and lateral view radiographs.[3]

Proper Pin Positioning[edit | edit source]

Pin Within Fracture Line[edit | edit source]

Review both AP and lateral views to confirm if any Schanz screws are within the fracture line.

  • Schanz Screw Within Fracture Line
    • Proximal Fragment Schanz Screw #2 (Near Pin)
    • Distal Fragment Schanz Screw #3 (Near Pin)
  • Schanz Screw Not Within Fracture Line
    • Proximal Fragment Schanz Screw #2 (Near Pin)
    • Distal Fragment Schanz Screw #3 (Near Pin)
If pin is within the fracture line, the patient must return to the operating room for pin removal and re-insertion of a new pin at least 2 cm away from the fracture line.

Pin Entry In Joint[edit | edit source]

Review both AP and lateral views to confirm if any Schanz screws have entered the knee or ankle joint.

  • Pin In Joint
    • Knee Joint
    • Ankle Joint
  • Pin Not In Joint
If pin is in a joint, the patient must return to the operating room for pin removal and re-insertion of a new pin outside of the joint.

Pin Perforation of Far Cortex[edit | edit source]

Review the AP view to confirm if any Schanz screws perforated the far cortex.[4]

  • Pin Perforation of Far Cortex
    • Proximal Fragment
      • Schanz Screw #1 (Far Pin)
      • Schanz Screw #2 (Near Pin)
    • Distal Fragment
      • Schanz Screw #3 (Near Pin)
      • Schanz Screw #4 (Far Pin)
  • No Pin Perforation of Far Cortex
If any pin perforates the far cortex, assess for neurovascular injury. 

Tibial Fracture Reduction[edit | edit source]

The acceptable parameters for a reduced open tibial shaft fracture are: (i) > 50% bone apposition;[5] and (ii) < 10 degrees of angulation in any plane.[6][7][8]

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.

  • Adequate Tibial Fracture Reduction
    • > 50% Bone Apposition; and
    • < 10 Degrees of Angulation in any Plane
  • Inadequate Tibial Fracture Reduction
    • < 50% Bone Apposition; or
    • > 10 Degrees of Angulation in any Plane
If the reduced tibial shaft fracture is not within acceptable parameters, the patient must return to the operating room for re-adjustment of fracture fragments.

Other Imaging Findings[edit | edit source]

Note other clinically significant radiographic findings.

Post-Operative Management Plan[edit | edit source]

Antibiotic Therapy[edit | edit source]

Antibiotics may be changed, added or extended depending on clinical findings.[9][10][11] Doses will be adjusted based on patient weight when indicated.

Recommended Antibiotic Therapies for Open Fractures*
Injury Characteristics Systemic Antibiotic Regimen Penicillin Allergy
Gustilo Type I and II Cefazolin 2 g IV immediately and q8 hours for a total of 3 doses[9][10][11] Clindamycin 900 mg IV immediately and q8 hours for a total of 3 doses
Gustilo Type III
  • Ceftriaxone 2 g IV immediately for a total of 1 dose, and
  • Vancomycin 1 g IV immediately and q12 hours for a total of 2 doses
  • Aztreonam 2 g IV immediately and q8 hours for a total of 3 doses, and
  • Vancomycin 1 g IV immediately and q12 hours for a total of 2 doses
Farm or fecal

contamination

Add Penicillin G IV (e.g., 5 million-10 million units/24 hours)[9][10] Add Metronidazole IV
Freshwater or

saltwater

contamination

Add Levofloxacin IV or Ciprofloxacin IV[11] Add Levofloxacin IV or Ciprofloxacin IV[11]
These therapies may vary due to regional differences in antibiotic regimens for open fractures.
Record the duration of intravenous antibiotic therapy in the patient's chart.

Venous Thromboembolism Prophylaxis[edit | edit source]

The Harborview Medical Center protocol for venous thromboembolism (VTE) prophylaxis for trauma patients is enoxaparin 40 mg (low molecular weight heparin) every 24 h.[12]

The contraindications for chemoprophylaxis of VTE are: "active bleeding in the last 48–72, hypertensive crisis, coagulopathy, platelet count < 25,000, used recombinant tissue plasminogen activator against stroke within 24 h, recent head trauma with central nervous system hemorrhage, multiple trauma with high bleeding risk, such as solid organ injury (suspected) peri-spinal hematoma, or at high risk for bleeding according to clinical judgment."

Wound Care[edit | edit source]

Wounds are cleaned with sterile normal saline and dressed with povidone iodine gauze dressing.

The frequency of dressing changings will vary according to the amount of wound contamination.

  • If the wound is highly contaminated, dressings are changed twice daily.
  • If the wound is clean, dressings can be changed once daily or every other day.

Early Mobilization[edit | edit source]

On post-operative day #2, the patient will be non-weightbearing and mobilized on axillary crutches.

Additional Surgical Procedures[edit | edit source]

If required, additional procedures can be performed 48 to 72 hours later for further debridement (a "second look") if the wound is still contaminated, and/or to adjust or replace the modular external fixator hardware. Hardware adjustment immediately after the initial application of the modular external fixator is not considered a fracture complication.

Post-operative AP and lateral radiographs will be obtained and reviewed.

Antibiotics may be changed, added or extended depending on clinical findings.

Discharge Instructions[edit | edit source]

After the final irrigation and debridement, patients will remain non-weight-bearing, and will be discharged typically within 48 hours on crutches with wound and pin care instructions.

The patient or caregiver should learn and apply the following wound and pin care instructions until the modular external fixator is removed:

  • Clean soft tissue wounds should be dressed with a non-adherent gauze dressing (like Sofra-Tulle) twice a week.
  • The pin insertion sites normally do not have to be dressed. However, if a clean environment and hygiene cannot be maintained after discharge, then gauze soaked in povidone iodine can be used to dress the pin insertion sites.
  • The pin insertion sites should be kept clean. If crust or exudate is present, then the pin insertion site can be cleaned with normal saline and disinfected with alcohol.
  • Pin insertion sites need not be protected for showering or bathing with clean water.[13]

Follow-up Care[edit | edit source]

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

Complications[edit | edit source]

Adverse events will be identified, reported, and monitored.

Potential post-operative complications include but are not limited to:

  • Acute Compartment Syndrome
  • Patellar Ligament Tethering
  • Tendon Rupture
  • Neurovascular Injury
  • Deep Venous Thrombosis/ Pulmonary Embolism
  • Fat Embolism
  • Pressure Injury (also known as a pressure sore or decubitus ulcer)
  • Sepsis
  • Shock
  • Death
  • Other:_______________________

Pin Removal and Replacement[edit | edit source]

  • Pin Removal and Replacement
    • Date of Procedure:_______________________
  • No Pin Removal and Replacement

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:_______________________
    • 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. Berg, E.E. and Murnaghan, J.J. Orthopedic Surgery: Diseases of the Musculoskeletal System. Essentials of surgical specialties, 2nd Edition. Edited by Peter F Lawrence. 514 pages, illustrated. Philadelphia: Lippincott Williams & Wilkins, 2000.
  2. https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/tibial-shaft/simple-fracture-transverse/modular-external-fixator#aftercare-following-external-fixation
  3. 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.
  4. 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.
  5. https://www.orthobullets.com/trauma/1045/tibial-shaft-fractures
  6. Nicoll EA. Fractures of the tibial shaft. A survey of 705 cases. J Bone Joint Surg Br. 1964 Aug;46:373-87.
  7. 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.
  8. 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.
  9. 9.0 9.1 9.2 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.
  10. 10.0 10.1 10.2 https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/tibial-shaft/further-reading/principles-of-management-of-open-fractures?searchurl=%2fSearchResults#principles-of-surgical-care-for-open-fractures
  11. 11.0 11.1 11.2 11.3 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.
  12. Gunning AC, Maier RV, de Rooij D, Leenen LPH, Hietbrink F. Venous thromboembolism (VTE) prophylaxis in severely injured patients: an international comparative assessment. Eur J Trauma Emerg Surg. 2021 Feb;47(1):137-143. doi: 10.1007/s00068-019-01208-z. Epub 2019 Aug 30. PMID: 31471670; PMCID: PMC7851035.
  13. https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/tibial-shaft/simple-fracture-transverse/modular-external-fixator#aftercare-following-external-fixation
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