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Tibial Plateau Fracture External Fixation

Preoperative Patient Care

A

Outpatient Management

1

Obtains focused history and performs focused exam

  • document distal neurovascular status
  • concomitant and associated orthopaedic injuries

2

Interpret basic imaging studies

  • triplanar films of the knee
  • AP
  • lateral
  • oblique

3

Prescribes nonoperative management

  • fracture brace
  • long leg cast

4

Make informed decision to proceed with operative treatment

  • describes accepted indications and contraindications for surgical intervention

5

Provides post-operative management and rehabilitation

  • postop: 2-3 week postoperative visit
  • continue physical therapy and range of motion exercises
  • discontinue DVT prophylaxis
  • wound check
  • staples/sutures removed
  • diagnose and management of early complications
  • continue toe partial weight-bearing at for additional for additional 6-9 weeks
  • postop: ~ 3 month postoperative visit
  • repeat radiographs
  • advance to full weightbearing
  • diagnosis and management of late complications
  • postop: 1 year postoperative visit
B

Advanced Evaluation and Management

1

Prioritizes the needs of the polytrauma patient

  • works with consulting

2

Complex wound management and debridement

  • understanding need for consultation for flap coverage

3

Capable of treating complications both intraoperatively and post-operatively

  • manages post operative infection
C

Preoperative H & P

1

Performs focused orthopaedic exam

  • check neurovascular status
  • check for compartment syndrome
  • check soft tissues

2

Appropriately orders basic imaging studies

  • order triplanar radiographs of the knee
  • AP
  • lateral
  • oblique

3

Perform operative consent

  • describe complications of surgery including
  • compartment syndrome
  • infection
  • superficial and deep wound problems
  • DVT

Operative Techniques

E

Preoperative Plan

1

Template fracture reductions

  • draw key fragments of fracture and plan for reduction

2

Execute surgical walkthrough

  • resident can describe key steps of the operation verbally to attending prior to beginning of case
  • describe potential complications and steps to avoid them
F

Room Preparation

1

Surgical instrumentation

  • External Fixation System

2

Room setup and equipment

  • radiolucent flat top table
  • c-arm fluoroscopy

3

Patient positioning

  • place patient supine
  • place a sterile bump or triangle under the knee
G

Proximal Pin Placement

1

Mark out the placement of the Schanz pins

2

Make a stab incision at the site of the pin placement

3

Bluntly dissect down to the bone

4

Place the proximal pins

  • place 2 Schanz pins alont the anterolateral thigh
  • place these pins in the midshaft of the femur
H

Distal Pin Placement

1

Mark the site of the tibial pin insertion

2

Make a stab incision at the site of pin placment

3

Bluntly dissect down to bone

4

Place the distal pins

  • place 2 Schanz pins into the midshaft and distal tibia
  • place the pins far enough away from the distal extension of the proximal tibia that there will be no interference in the event future incisions are needed for definitive fixation
I

Bar Placement

1

Loosley place a bar to connect the proximal and distal pins

  • place a solitary bar to span all of the pins
J

Reduction

1

Reduce the fracture

  • perform longitudinal traction to reduce the fracture

2

Confirm placement

  • confirm under fluoroscopy

3

Position the knee

  • maintain slight flexion of the knee
  • check reduction with fluoroscopy
K

Final Tightening

1

Tighten the external fixator

  • tighten all of the connectors
  • this is done to maintain ligamentotaxis reduction
L

Multibar Fixation (optional)

1

Irrigation, hemostasis, and drain

  • connect the two proximal pins using a single bar
  • connect the two distal pins using another bar
  • these bars are then used to manipulate the fracture to achieve reduction of the plateau

2

place a third bar to connect the proximal and distal bars

  • tighten the bars to maintain reduction

Postoperative Patient Care

O

Perioperative Inpatient Management

1

Write comprehensive admission orders

  • advance diet as tolerated
  • pain control
  • prescribe appropriate DVT prophylaxis
  • wound management
  • pin care
  • check appropriate labs
  • antibiotics

2

Check radiographs in postop

  • check placement of pins

3

Initiate physical therapy on POD 1

4

Appropriate medical management and medical consultation

5

Discharges patient appropriately

  • pain meds
  • outpatient physical therapy
  • schedule 2 week follow up
R

Complex Patient Care

1

Develops unique, complex post-operative management plans

 

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