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Tibial Plafond Fracture External Fixation

Planning

B

Preoperative Plan

1

Template fracture

  • template fracture pattern and instrumentation

2

Execute surgical walkthrough

  • describe steps of the procedure verbally to the attending prior to the start of the case
  • describe potential complications and steps to avoid them
C

Room Preparation

1

Surgical instrumentation

  • external fixation system

2

Patient positioning

  • patient supine with feet at the end of the bed, small bump under ipsilateral thigh, tourniquet on thigh
  • if external fixator in place need to scrub down frame and pins thoroughly as this is a source of contamination

3

OR setup and C-arm

  • radiolucent OR table
  • c-arm from contralateral side perpendicular to bed

Technique

D

Tibial Pin Placement

1

Mark and make the incision at the site of tibial pin insertion

2

Bluntly dissect down to bone

3

Place the tibial pins

  • place 2 Schanz pins into the midshaft of the tibia
  • avoid placing the pins in comprosied soft tissue and any fracture extension

4

Confirm the location with fluoroscopy

E

Calcaneal Pin Placement

1

Mark and make a skin incision at the site of the calcaneus pin insertion

2

Perform blunt dissection down to bone

3

Place the calcaneal pin

  • place a centrally threaded transfixation pin through the calcaneal tuberosity from medial to lateral
  • placing the pin in this direction helps avoid the posterior tibial artery
  • the location for this pin is 1.5 cm anterior to the posterior aspect of the heel and 1.5 cm proximal to the plantar aspect of the heel

4

Confirm the location with fluoroscopy

F

Bar Placement

1

Connect the tibial pins

  • place a solitary bar to connect the tibial pins

2

Place bars on the calcaneal pins

  • connect medial and lateral bars to each side of the heel
  • this makes a triangular configuration
G

Reduction

1

Reduce the fracture

  • perform longitudinal traction to obtain length
  • be sure to obtain the appropriate anteroposterior reduction
H

Metatarsal Pin Placement

1

Place the metatarsal pin

  • place a pin into the base of the first or second metatarsal
  • this maintains a plantigrade foot along with alignment

2

Connect the metatarsal pin to the mainframe

  • connect this forefoot pin to the main frame with connecting bar
  • hold the foot in neutral dorsiflexion
I

Reduction Confirmation

1

Take final fluoro AP/Lat/Mortise of ankle and AP/Lat of tibia/fibula

2

Check limb length, rotation, and alignment

Patient Care

K

Preoperative H & P

1

Obtain history and perform basic physical exam

  • document neurovascular status
  • check compartments

2

Order basic imaging studies

  • order biplanar radiographs of the tibia and weight bearing triplanar radiographs of the ankle

3

Splint fracture appropriately

  • place in posterior splint with stirrups

4

Perform preoperative consent

  • wound breakdown (10%)
  • superficial/deep infection (5-15%)
  • malunion
  • nonunion
  • post-traumatic arthritis (30-70% depending on articular injury)
  • ankle stiffness
  • neurovascular injury
L

Perioperative Inpatient Management

1

Write comprehensive admission orders

  • Serial compartment checks x24 hours
  • IV fluids
  • DVT prophylaxis
  • pain control
  • advance diet as tolerated
  • check appropriate labs
  • wound care
  • pin care
  • appropriately orders and interprets basic imaging studies
  • xrays of the ankle in postop

2

Appropriate medical management and medical consultation

3

Inpatient physical therapy

  • non weightbearing
  • crutches for ambulation

4

Discharge home appropriately

  • pain meds
  • outpatient PT
  • schedule follow up appointment in 2 weeks
M

Outpatient Evaluation and Management

1

Obtain focused history and perform focused exam

  • evaluate degree of soft tissue injury
  • open wounds
  • swelling (fracture blisters)
  • deformity
  • check soft tissue for wrinkles
  • await return of skin wrinkles prior to ORIF to decrease wound complications for 10-14 days
  • check compartments
  • identify risk factors that correlate with complications and poor outcomes
  • comorbidities
  • diabetes
  • social factors
  • smoking

2

Appropriately interprets basic imaging studies

  • AP/Lat/Mortise views of ankle, AP/Lat views of tibia/fibula
  • characterize fracture pattern, amount of comminution, metaphyseal bone loss, shortening, and angulation
  • commonly 3 fragments according to ankle ligaments: medial malleolar (deltoid), anterolateral (AITFL, Chaput), and posterolateral (PITFL, Volkmann) fragments
  • 75% of fractures have associated fibula fractures
  • location and angulation of fracture fragments influences surgical approach
  • severely comminuted fractures with poor bone quality may require definitive management with external fixator vs. tibiotalar arthrodesis
  • CT scan
  • often performed after placement of spanning ankle external fixator to delineate fracture fragments once length restored

3

Makes informed decision to proceed with operative treatment

  • describes accepted indications and contraindications for surgical intervention

4

Provides post-operative management and rehabilitation

  • immediate Post-op
  • non-weight bearing in splint vs. external fixator, crutches for ambulation
  • 2 weeks post-op
  • wound check
  • repeat xrays of ankle and tibia/fibula
  • 8-12 weeks postop
  • xrays to evaluate union and fracture consolidation
  • range of motion exercises to ankle
  • advance weight bearing status and rehabilitation
N

Advanced Evaluation and Management

1

Provides comprehensive assessment of complex fracture patterns on imaging studies

2

Recognizes indications for and provides non-operative treatment of an unstable fracture

  • diabetes
  • medical comorbidities
  • noncompliance
O

Complex Patient Care

1

Develops unique, complex post-operative management plans

 

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