External Fixators for Distal Tibial Frx : Wheeless' Textbook of Orthopaedics

- See: IM Nailing for Distal Tibia Fracture

- Discussion:
    - outcomes:
            - in a retrospecitive study, external fixation was considered a risk factor for non union (29% non union rate);
            - Distal tibia fractures: management and complications of 101 cases

    - reduction:
- usually should be carried out prior to fixator application;
            - care is taken to ensure proper tibial rotation (center of patell to tibial tubercle creates a line to the 2nd toe)
    - plate fixation of fibula:
            - The role of fibular fixation in combined fractures of the tibia and fibula: a biomechanical investigation.
            - Plating of the fibula. Its potential value as an adjunct to external fixation of the tibia.
          - The effect of concurrent fibular fracture on the fixation of distal tibia fractures: a laboratory comparison of intramedullary nails with locked plates.
            - [Role of the fibula in distal tibial fracture]
    - plane of the fixator:
- consider the need for soft tissue coverage and position the fixator in way that not to interfere with free flap coverage;
- because major bending moments on tibia during gait are in saggital plane, placment of fixator pins and frame near saggital plane improves stability;

    - safe zone of pin insertion:
             - need to avoid muscle impalement:
             - avoid impaling anterior tibial or toe extensor tendons;
             - w/ external fixators about the ankle, there is greater incidence of drainage from transfixtion that passed thru middle of anterior compartment than from half pins placed through medial tibia which underlies rather stationary subQ tissues;
             - references:
                     - Extracapsular Placement of Distal Tibial Transfixation Wires.
                     - Soft tissue injuries with the use of safe corridors for transfixion wire placement during external fixation of distal tibia fractures: an anatomic study.
                     - Anatomy of the distal knee joint and pyarthrosis following external fixation.
                     - The proximal extent of the ankle capsule and safety for the insertion of percutaneous fine wires.

    - enhancement of fixator stability
    - foot inclusion: may be indicated for open fractures and distal fractures;
- choice of hardware:
- uniplanar fixators: Synthes and Orthofix fixator;
- circular wire fixators: Ilizarov Menu, Synthes Hybrid Fixator, Orthofix Hybrid System;
    - dynamization:
- alawys consider the need for postoperative dynamization, hence plan the configuration to allow for shortening;
- this is especially important for the orthofix fixator since postoperative shortening will not be possible unless the fixator is initially lengthened;
            - reference:
                   - Dynamization timing and its effect on bone healing when using the Orthofix Dynamic Axial Fixator.