Uniplanar External Fixation/Knowledge Review

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 uniplanar external fixator frame 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[edit | edit source]

By the end of this module, learners will:

1. Know the blood supply to the tibia
2. Know the nerves that supply the tibia
3. Know the safe zones in the tibia for pin insertion
4. Know how to apply the Gustilo Open Fracture Classification to open tibial shaft fractures
5. Understand how the Gustilo Open Fracture Classification impacts the selection of antibiotic therapy for open tibial shaft fractures
6. Know the principles of surgical care and management for open tibial shaft fractures, including soft tissue management
7. Know the indications for uniplanar external fixation for a patient with an open tibial shaft fracture
8. Know the indications for referral of a patient with an open tibial shaft fracture to a tertiary center for specialist care
9. Know the acceptable parameters for reduction of open tibial shaft fractures

Anatomy Review[edit | edit source]

• Blood Supply to the Tibia

• AO Surgery Reference: Safe Zones of the Tibia for Pin Insertion

Gustilo Open Fracture Classification[edit | edit source]

Table 1. Gustilo Open Fracture Classification^[3][4]

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.

The Gustilo Open-Fracture Classification impacts the selection of antibiotic therapy for open tibial shaft fractures:

• Antibiotics based on Gustilo Classification

Antibiotic Therapy[edit | edit source]

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

Table 2. 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[5][6][7]	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)[5][6]	Add Metronidazole IV
Freshwater or saltwater contamination	Add Levofloxacin IV or Ciprofloxacin IV[7]	Add Levofloxacin IV or Ciprofloxacin IV[7]

Principles of Management of Open Tibial Shaft Fractures[edit | edit source]

• AO Surgery Reference: Principles of Management of Open Fractures
• Open Fractures Management
• Treatment of Open Tibia Fractures in Low Income Countries (LICs)
• Tibial Shaft Fractures

Indications for Uniplanar External Fixation for an Open Tibial Shaft Fracture[edit | edit source]

After completing the entire module, learners should be able to perform uniplanar external fixation of open tibial shaft fractures with the following features:

• Able to directly visualize fracture through the open wound or intraoperative extension of the wound; and
• Gustilo Type II or Gustilo Type IIIA open tibial fracture; and
• Non-comminuted, tibial shaft (extra-articular) fracture; and
• With or without a fibular shaft (extra-articular) fracture

Indications for Referral to a Tertiary Center for Specialist Care[edit | edit source]

• Unable to directly visualize fracture through the open wound or intraoperative extension of the wound
• Non-palpable pedal pulse
• Symptoms consistent with acute compartment syndrome
• Gustilo Type IIIB or Gustilo Type IIIC open tibial fracture
• Comminuted or segmental tibial fracture
• Bilateral tibia fractures
• Metaphyseal tibial fracture with intra-articular extension
• Concomitant distal fibular fracture near or involving the ankle joint
• Concomitant ipsilateral or contralateral femoral fracture
• Severe traumatic brain injury (Glasgow Coma Scale <12)
• Severe spinal cord injury (lower extremity paresis/paralysis)
• Severe burns (involving >10% of the total body surface area or >5% of the total body surface area with full-thickness or circumferential injury)

Reduction Parameters for an Open Tibial Shaft Fracture[edit | edit source]

The acceptable reduction parameters for open tibial shaft fractures are:

• Bone apposition > 50%
• Rotation < 10 degrees
• Angulation < 10 degrees in any plane
• Length discrepancy < 2 cm shortening
• No distraction (lengthening)^{[1][9][10][11][12]}

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]