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Tibia Frx: Post Operative Care

- Considerations:
    - pin care:
          - tissue motion impairs tissue resistance to infection;
          - excess motion at pin skin interface can be reduced by wrapping sterile gauze between the pin clamp and skin;
          - surgical sponges around pins may prevent the skin from pistoning up and down over the wire, thus reducing pin tract contamination;
    - time for healing:   (prognosis for healing)
          - grade I Fractures:  4.7 months (8% require grafting)
          - grade III Fractures:  8.8 months (71% require Grafting)
          - 0.5 cm fracture gap: 12-18 months
    - bone grafting:
          - probably 40-60% of grade III fractures will require bone grafting;
    - dynamization:
    - exchange nailing:
          - some recommend change to internal fixation after healing of soft tissues and all pin sites to avoid these complications;
                  - 8 to 12 weeks after injury as the ideal time for such conversion;
    - wt bearing:
          - amount of wt bearing should be proportional to frx stability;
          - to minimize stress on the pins, full wt bearing should be avoided unless compression can be placed across the fracture site, w/ the majority of the axial load applied to bone;
          - segmental defect or bicortical communution:
                  - minimal wt bearing is maintained in order not to loosen pin bone  interface;
                  - hence only touch down wt bearing should be permitted to protect pin tracts from excessive motion and stress over load;

- Complications:
    - angulation:
          - angulation following fixator removal is one of the most common complications associated with external fixation;
          - 8% loss of good alignment and average valgus angulation of 8 deg;
          - this can be avoided by not removing fixator until adequate callus is present radiographically;
          - this can be avoided by protecting the fracture with a cast;
    - refracture: if external fixator is removed prematurely, refracture rate may be 10%;
    - equinus deformity:
    - loss of knee motion:
    - non union:
          - approx 5% (closed) and 12% (open);
          - consider early fibulectomy to encourage healing;
          - consider early prophylactic bone grafting for unstable fractures (major comminution, bone loss, open frx);
                 - bone grafting may be required in 20% of all patients;
          - following frame removal 1/3 of patients require additional casting for an average of 5 months;
    - pin problems:
          - over half of external fixators will have at least one problematic pin;
          - pin drainage: expect that at least one pin (out of the entire group) will have drainage in 80% of cases;
          - w/ worsening signs of inflammation and drainage can be managed with oral antibiotics;
          - persistent drainage is not an indication for pin removal if there is no radiolucency around the pins;
          - pin loosening: (5-7%)
          - deep infection in 4% (see osteomyelitis in the tibia)
                 - minor pin tract infection requiring removal of pins and curettage: 9%
                 - major pin tract infections requiring pin removal, curettage, and implantation of gentamicin impregnated PMMA beads: 3%

Tibial external fixation, weight bearing, and fracture movement.

Chronic osteomyelitis in pin tracks.

Cortical Bone Reactions at the Interface of External Fixation Half-Pins Under Different Loading Conditions.

Pin track infections: A canine model.