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 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.

It's highly recommended to: (i) print off this checklist and review it before simulation skills training, (ii) have an assistant read out and complete this checklist to verify that all the steps are properly performed during the simulation skills training, and (iii) file and save a back-up copy for your training records.

Training Logbook[edit | edit source]

Please print out the Training Logbook below and write your name, your assistant's name, and date of training at the bottom of the Training Logbook.

Training Logbook - Modular External Fixation for an Open Tibial Shaft Transverse Fracture
# Self-Assessment Checklist Circle the most appropriate response
1A Wore proper eye protection and gloves Done Correctly / Done Incorrectly / Not Done
1B Performed simulated 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) Done Correctly / Done Incorrectly / Not Done
1C Debrided all foreign material and non-viable tissue This Step Cannot Be Performed During Simulation Training But Must Be Performed During the Actual Clinical Procedure
2A Placed 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 Done Correctly / Done Incorrectly / Not Done
2B Positioned the “far” Schanz screw (furthest from the fracture line) in the proximal fragment in the anteromedial tibial wall medial or distal to the tibial tuberosity while avoiding traumatized soft tissues Done Correctly / Done Incorrectly / Not Done
2C Placed the "far" Schanz screw in the distal fragment at least two fingers’ breadth proximal to the medial malleolus while avoiding traumatized soft tissues This Step Cannot Be Performed During Simulation Training But Must Be Performed During the Actual Clinical Procedure
2D Positioned 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 Done Correctly / Done Incorrectly / Not Done
2E Used a 22 blade scalpel to make a stab incision in the soft tissue overlying the anteromedial tibial wall for each Schanz screw This Step Cannot Be Performed During Simulation Training But Must Be Performed During the Actual Clinical Procedure
2F Used dissecting scissors to spread the soft tissue apart in each stab incision to expose the bone for drilling This Step Cannot Be Performed During Simulation Training But Must Be Performed During the Actual Clinical Procedure
3A Prepared 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 Done Correctly / Done Incorrectly / Not Done
3B Confirmed that the drill is ready for use by pressing the on/off trigger and observing that the Schanz screw tip is rotating clockwise when the drill is pointing forward Done Correctly / Done Incorrectly / Not Done
3C Used the properly sized drill sleeve and held the drill sleeve at least 3.0 mm above the near cortex during this simulation training Done Correctly / Done Incorrectly / Not Done
3D Used the properly sized drill sleeve and placed the drill sleeve directly on the cortex in each stab incision to protect the surrounding soft tissues when drilling in the real clinical procedure This Step Cannot Be Performed During Simulation Training But Must Be Performed During the Actual Clinical Procedure
3E Placed each Schanz screw tip directly on the near cortex of the anteromedial tibial wall and not on the anterior tibial crest Done Correctly / Done Incorrectly / Not Done
3F Inserted the near and far Schanz screws in the proximal fragment at a drill trajectory angle between 20°-60° relative to the tibial crest Done Correctly / Done Incorrectly / Not Done
3G Inserted the near and far Schanz screws in the distal fragment at a drill trajectory angle between 30°-90° relative to the tibial crest Done Correctly / Done Incorrectly / Not Done
4A Directed an assistant to simulate irrigation with an empty syringe while drilling Done Correctly / Done Incorrectly / Not Done
4B Placed each Schanz screw tip on the anteromedial tibial wall, started drilling with the screw tip rotating in a clockwise direction, and ensured that the tip did not slip on the near cortex Done Correctly / Done Incorrectly / Not Done
4C Power drilled all four Schanz screws through the near cortex and used tactile and acoustic feedback to stop drilling after passing through the near cortex and before or when the inner surface of the far cortex was reached Done Correctly / Done Incorrectly / Not Done
5A Inserted the chuck key into the opening in the drill, turned the chuck key anticlockwise, detached the drill from the Schanz screw, and removed the drill sleeve from the Schanz screw Done Correctly / Done Incorrectly / Not Done
5B Slid the universal chuck with T-handle over each Schanz screw, and tightened the chuck over the Schanz screw Done Correctly / Done Incorrectly / Not Done
5C Used the universal chuck with 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 Done Correctly / Done Incorrectly / Not Done
5D Detached the universal chuck with T-handle from each Schanz screw Done Correctly / Done Incorrectly / Not Done
6A Applied the pin-to-rod clamps to connect the two Schanz screws in each fragment to a 250 mm rod Done Correctly / Done Incorrectly / Not Done
6B Tightened the pin-to-rod clamps initially by hand and then applied and turned the 11 mm spanner with T-handle wrench clockwise for final tightening Done Correctly / Done Incorrectly / Not Done
7A Applied 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 Done Correctly / Done Incorrectly / Not Done
8A Loosened the right vise clamp securing the distal fragment to simulate a displaced fracture and used the two 250 mm rods as handles to manually reduce the fracture and adequately restore alignment
  • Bone apposition > 50%
  • Angulation < 10 degrees in any plane
  • Rotation < 10 degrees
Done Correctly / Done Incorrectly / Not Done
8B Manipulated the two near Schanz screws to compress the fragments together
  • Length discrepancy < 2 cm shortening
  • No distraction (lengthening)
Done Correctly / Done Incorrectly / Not Done
9A Used an assistant to stabilize the reduced and compressed fracture while using the spanner with T handle wrench for final tightening of the rod-to-rod clamps around the 200 mm connecting rod Done Correctly / Done Incorrectly / Not Done
9B Verified the reduction visually, and with gentle palpation of the tibial crest at the fracture line to confirm whether alignment has been adequately restored
  • Bone apposition > 50%
  • Rotation < 10 degrees
Done Correctly / Done Incorrectly / Not Done
9C Visually checked the position of the big toe and the alignment of the middle of the second toe with the center of patella to confirm whether rotational alignment has been adequately restored
  • Rotation < 10 degrees (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)
This Step Cannot Be Performed During Simulation Training But Must Be Performed During the Actual Clinical Procedure
9D Visually inspected the fracture line to confirm that the reduction is adequate during this simulation training
  • Length discrepancy < 2 cm shortening
  • No distraction (lengthening)
Done Correctly / Done Incorrectly / Not Done
9E Palpated the medial malleolus of both limbs under sterile conditions to estimate and compare the length of the reduced limb to the uninjured contralateral limb
  • Length discrepancy < 2 cm shortening
  • No distraction (lengthening)
This Step Cannot Be Performed During Simulation Training But Must Be Performed During the Actual Clinical Procedure
9F If required, adjusted the fragments to achieve an adequate reduction
  • Bone apposition > 50%
  • Rotation < 10 degrees
  • Angulation < 10 degrees in any plane
  • Length discrepancy < 2 cm shortening
  • No distraction (lengthening)
Done Correctly / Done Incorrectly / Not Done / Not Applicable
9G Checked for skin tenting around Schanz screws and if present, widened the stab incision to release soft tissue tension around the pin site This Step Cannot Be Performed During Simulation Training But Must Be Performed During the Actual Clinical Procedure
10A Cleaned the extremity and applied sterile gauze dressings to all four pin sites This Step Cannot Be Performed During Simulation Training But Must Be Performed During the Actual Clinical Procedure
10B Used a measuring tape to measure and compare the limb length (from anterior superior iliac spine to the medial malleolus) of both legs after dressings have been applied
  • Length discrepancy < 2 cm shortening (compared to uninjured, contralateral leg)
  • No distraction (lengthening)
This Step Cannot Be Performed During Simulation Training But Must Be Performed During the Actual Clinical Procedure
10C Re-evaluated the Gustilo open-fracture classification in the operating room, and updated the antibiotic regimen and surgical treatment plan accordingly This Step Cannot Be Performed During Simulation Training But Must Be Performed During the Actual Clinical Procedure
11A Took an anterior view photo with a ruler in the image to provide scale Done Correctly / Done Incorrectly / Not Done
11B Visually inspected the tibial shaft in the anterior photo and confirmed that alignment is within acceptable parameters:
  • Bone apposition > 50%
  • Rotation < 10 degrees
  • Angulation < 10 degrees in any plane
Done Correctly / Done Incorrectly / Not Done
11C Used a ruler to measure the distance of the two near Schanz screws from the fracture line Done Correctly / Done Incorrectly / Not Done
11D The two near Schanz screws were placed at least 2.0 cm (a finger breadth) from the fracture line Done Correctly / Done Incorrectly / Not Done
11E Visually inspected the fracture line to confirm that the reduction is adequate:
  • length discrepancy < 2 cm shortening
  • no distraction (lengthening)
Done Correctly / Done Incorrectly / Not Done
12A Took a medial view photo Done Correctly / Done Incorrectly / Not Done
12B The far Schanz screw in the proximal fragment was inserted medial or distal to the tibial tuberosity Done Correctly / Done Incorrectly / Not Done
12C All four Schanz screws were inserted medial to the anterior tibial crest in the medial photo Done Correctly / Done Incorrectly / Not Done
13A Took a lateral view photo Done Correctly / Done Incorrectly / Not Done
13B All four Schanz screws did not perforate the far cortex in the lateral photo Done Correctly / Done Incorrectly / Not Done
13C Visually inspected the tibial crest in the lateral photo and confirmed that alignment is within acceptable parameters:
  • Bone apposition > 50%
  • Rotation < 10 degrees
  • Angulation < 10 degrees in any plane
Done Correctly / Done Incorrectly / Not Done
14A Removed the rods and clamps but left the four Schanz screws in the distal and proximal fragments, used scissors to cut the cellophane wrap overlying the fracture site to separate the two fragments, removed each fragment from the vise clamp, and placed each fragment on a flat surface for inspection of the drill trajectory angles Done Correctly / Done Incorrectly / Not Done
14B Placed a protractor on the cross-section of the proximal fragment and lined up the center vertical black line of the protractor with the center of the vise attachment Done Correctly / Done Incorrectly / Not Done
14C Took an overhead ("bird's eye view") photo of the cross-section of the proximal fragment to record the drill trajectory angles relative to the tibial crest and checked that the center vertical black line of the protractor was lined up with the center of the vise Done Correctly / Done Incorrectly / Not Done
14D For the proximal fragment, the drill trajectory angles of both Schanz screws was between 20°-60° relative to the tibial crest Done Correctly / Done Incorrectly / Not Done
15A Placed a protractor on the cross-section of the distal fragment and lined up the center vertical black line of the protractor with the center of the vise attachment Done Correctly / Done Incorrectly / Not Done
15B Took an overhead ("bird's eye view") photo of the cross-section of the distal fragment to record the drill trajectory angles relative to the tibial crest and checked that the center vertical black line of the protractor was lined up with the center of the vise Done Correctly / Done Incorrectly / Not Done
15C For the distal fragment, the drill trajectory angles of both Schanz screws was between 30°-90° relative to the tibial crest Done Correctly / Done Incorrectly / Not Done
16A Provided specific, clear, and concise directions to the assistant during the simulated procedure Done Correctly / Done Incorrectly / Not Done
17A Photographed this completed training logbook on a cellphone as a backup and filed this original completed training logbook in your training records. Done Correctly / Done Incorrectly / Not Done

The learner must perform all the checklist items correctly (except for the steps that cannot be performed during simulation training) in order to pass this module.

Learner's Nameː

Learner's Signature:

Assistant's Nameː

Assistant's Signature:

Date of Trainingː

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.

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