Uniplanar External Fixation/Knowledge Review/Follow-Up Care

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 be able to:

1. Provide follow-up care for a patient following uniplanar external fixation of an open tibial shaft fracture.
2. Review the follow-up anteroposterior and lateral view radiographs of a patient following uniplanar 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 complications.

Follow-Up Clinical Assessment[edit | edit source]

The purpose of applying an uniplanar external fixator is to permit wound care of an open fracture before skin coverage of soft tissue wounds and to provide temporary stabilization of an open fracture before definitive fracture treatment.

Physical Examination[edit | edit source]

Extremity Inspection[edit | edit source]

Wound size:_________________________ cm

	Clinical Signs	Check the most appropriate response	Management
Clean wound	No wound contamination	Yes No	If the wound is still contaminated, additional surgical debridement must be performed until the wound is clean.
Healing wound	Granulation (velvety red) tissue in wound bed	Yes No	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 infection	Local erythema Swelling Tenderness Purulent discharge	Yes No	If there are signs of a 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]
Fracture-related infection	Fistula, sinus or wound breakdown (with communication to the bone or the implant); or Purulent drainage from the wound[1]	Yes No	If there are clinical signs of a fracture-related infection, the patient should be referred to a tertiary center for specialist care.[1]

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 to assess healing progress at follow-up visits.

Hardware Inspection[edit | edit source]

Hardware Issue	Clinical Signs	Check the most appropriate response	Management
Pin site infection	Cellulitis around the pin site (i.e., local erythema, swelling, tenderness) Discharge from the pin site	Yes No	Pin site infections are not considered surgical site infections.[2] If a pin site infection is present, the pin site should be cleaned daily and a short course of antibiotics may be given. Pin site infections do not require surgical removal of the pin unless the infection persists and leads to pin loosening.
Pin loosening	Pain around the pin site Seropurulent discharge from the pin site[3] Pin can be freely turned by hand when the pin-to-rod clamp is loosened	Yes No	Normally, a pin cannot be turned by hand when the pin-to-rod clamp is loosened. If a pin site infection persists leading to pin loosening, the pin should be removed in the operating room, > two deep tissue specimens (i.e., pin tract curettes) should be taken to obtain wound cultures, and a new pin should be inserted 2.0 cm from the original pin site.[1]
Pin failure	Broken pin	Yes No	A broken pin should be removed in the operating room and a new pin inserted 2.0 cm from the original pin site.
Frame loosening	Clamp(s) not securely tightened	Yes No	Use the 11 mm spanner with T handle to tighten the clamps at the bedside.
Frame component failure	Broken clamp(s) or rod	Yes No	Replace the failed component at the bedside 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.

Joint Motion	Active or Passive Range of Motion	Range of Motion	Compare Both Sides
Knee flexion	Active range of motion Passive range of motion only	Normal (135°) Abnormal: ________°	Symmetric Asymmetric
Knee extension	Active range of motion Passive range of motion only	Normal (0°) Abnormal: ________°	Symmetric Asymmetric
Ankle dorsiflexion	Active range of motion Passive range of motion only	Normal (20°) Abnormal: ________°	Symmetric Asymmetric
Ankle plantarflexion	Active range of motion Passive range of motion only	Normal (50°) Abnormal: ________°	Symmetric Asymmetric

Follow-Up Radiographic Findings[edit | edit source]

Obtain anteroposterior (AP) and lateral view radiographs at 2, 6, and 12 weeks post-discharge in follow-up clinic visits. Note any clinically significant radiographic findings.

X-Ray Feature	Check the most appropriate response	Management
Maintenance of reduction: the acceptable parameters for a reduced tibial fracture are: > 50% bone apposition;[4] and < 10 degrees of angulation in the coronal or saggital plane.[2][5][6]	Yes No	If reduction is not maintained, check for hardware loosening and ensure the frame 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 fracture treatment with plaster of Paris casting (if bone apposition is > 50%) or internal fixation (if an orthopedic specialist is locally available).
Pin site fracture	Yes No	If a fracture around a pin occurs, refer patient to a tertiary center for specialist care.
Osteonecrosis is defined as in situ death of bone tissue due to loss of blood supply. It can be seen on X-ray as a ring sequestrate (Figure A) encircling the implant.[9][10] The primary symptom of osteonecrosis is pain.	Yes No	If signs of osteonecrosis are present, refer patient to a tertiary center for specialist care.

Follow-up Care Plan[edit | edit source]

Visit Schedule[edit | edit source]

Patients should be ideally followed up in the clinic at 2 weeks, 4 weeks, 6 weeks, 8 weeks, 12 weeks, 6 months, and 1 year or as per local practices.

Physical Therapy[edit | edit source]

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

Skin Coverage Options[edit | edit source]

Skin coverage of soft tissue wounds usually occurs at 2 to 4 weeks. Once the wound is clean, the skin coverage options are:

Secondary Intention

Tertiary Intention (Delayed Wound Closure)

Suture Closure (if wound size is < 4 cm which is approximately 2 fingers' breadth)

Refer to a local plastic and reconstructive surgeon for:

Skin Graft

Local Flap

Distal Flap

Free Flap

Other: __________________________________

Definitive Fracture Treatment Options[edit | edit source]

Once the wound is clean, the uniplanar external fixator can be removed, and definitive fracture treatment can be applied:

Plaster of Paris Casting; or

Internal Fixation

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

Once the wound is clean, and if bone apposition is > 50%:

1. the uniplanar external fixator frame (4 universal pin-to-rod clamps and uniplanar rod) will be removed using a sterile 11 mm spanner with T-handle while wearing sterile gloves in the casting room of the clinic;
2. the uniplanar external fixator pins will be removed using a sterile universal chuck with T-handle while wearing sterile gloves (no anesthesia is required);
3. the pin insertion sites will be covered with sterile gauze; and
4. a long leg Plaster of Paris cast will be applied by the physician or orthopedic cast technician.

Please review the following learning resources:

1. Casting of the Lower Limb - General introduction to nonoperative fracture care (please be sure to review the 1:01 hour long AO teaching video: "Non-operative fracture care - Established procedures and contemporary techniques" in English)
2. Cast Treatment of Tibial Fractures
3. Simple, Transverse Tibial Fracture Indications - Nonoperative (casting) (please scroll down to Nonoperative (casting) and click on "Read full indications")
4. Videos from "Casts, Splints, and Support Bandages—Nonoperative Treatment and Perioperative Protection" (please scroll down to and be sure to review the 11:27 minute long AO teaching video: "Long leg cast using plaster of Paris" in English)

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.^[11]

Please review the following learning resources:

1. Basic Treatment Techniques for Simple, Transverse Tibial Fractures - Nonoperative (casting) (please be sure to review the 13:37 minute long AO teaching video: "Patella tendon bearing cast (PTB)" in English)
2. Applying a patella tendon bearing (PTB) cast

Definitive Internal Fixation[edit | edit source]

Once wound is clean, 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.

Functional Assessment After Cast Removal[edit | edit source]

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

History[edit | edit source]

Pain, tenderness or abnormal motion at fracture site

Able to return to normal work activities

Physical Examination[edit | edit source]

Observe if patient can squat and smile

Radiographic Findings[edit | edit source]

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

Note any clinically significant radiographic findings:____________________________________

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][12] _______________

Tibial Fracture Healed Radiographically

Yes (Total mRUST Score > 11)

No (Total mRUST Score < 11)

Fracture Complications[edit | edit source]

X-Ray Feature	Check the most appropriate response	Management
Malalignment is defined by one or more of the following features: < 50% bone apposition >10 degrees of angulation in the coronal or saggital plane > 10 degrees of rotation > 2 cm length shortening any distraction.[2][4][5][13][14]	Yes No	If malalignment is not corrected at the time of definitive fracture treatment, refer patient to a tertiary center for specialist care.
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: leg length discrepancy (> 2 cm shortening) angular malalignment (> 10 degrees of angulation in the coronal or saggital plane) malrotation (> 10 degrees).[2][4][5][6][14][15]	Yes No	If malunion occurs in a healed fracture, refer patient to a tertiary center for specialist care.
Delayed union is diagnosed when the fracture unites between 4-6 months.	Yes No	If union is delayed at 4 months, refer patient to a tertiary center for specialist care.
A nonunion is defined as: an mRUST score of <10 at or after the 6 month follow-up visit; or failure of the fracture to heal beyond 6 months from the date of injury.[2][12][15]	Yes No	If nonunion occurs, refer patient to a tertiary center for specialist care.
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.[9][10]	Yes No	If signs of osteonecrosis are present, refer patient 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]