Pitfalls and complications

• The problem of knee pain: It is seen in approximately 30% of the patients. Generally, this problem occurs due to improper entry point of nail entry.

• Irritation of the patellar ligament: It is caused if the nail is left proud.

• Pain and irritation: Generally, pain and irritation may be caused by an incision about the anterior aspect of the knee particularly in kneeling.

• Breakage of interlocking screws: This is usually a common complication. This occurs particularly when the smaller nails are used and in open fractures as union takes a longer time in these fractures.

External fixation

External fixation is suggested in open fractures with bone loss, in fractures where orthopedic implants like plates and nails would remain exposed, and in severe open fractures. Additionally, it is preferable in serious multi-trauma cases where the fractures need to be stabilized appropriately with no further insult to the patient. Application of external fixation as a supplement to internal fixation (lateral bridge plate and medial external fixator) or as a joint bridging device can be suggested. In these cases, external fixation is carried out for temporary fixation so it needs to be followed by internal fixation.

These orthopedic implants for external fixation are available with external fixator suppliers.

Surgical anatomy

For internal fixation in the tibia, the appropriate zone of anatomy is considered upon so that devices such as half pins, transfixing pins, or Schanz screws can be placed through that without the involvement of nerves, vessels, muscles, or tendons. Only thin wires of 1.8–2 mm must be used for transfixation as these wires have a wider range for placement. The safe zones for placement of half pins are an arc of nearly 220° proximally, 120° distally, and 140° in the diaphysis.

Preoperative planning

The goal of external fixation is to provide stable conditions for safe healing of soft-tissue and wound management temporarily. Therefore, the construct of the frame needs to be simpler so that it can allow full access to the wound, and the secondary soft-tissue procedures for e.g. free tissue transfer, grafts, flaps, and definitive internal fixation can be performed if required. All the components of the frame should be assembled prior to the application so that time can be saved.

Reduction techniques

For the reduction of the fracture, an external fixator can be applied particularly when the tube-to-tube principle is followed

Choice of implant

In most diaphyseal fractures, a unilateral half pin frame is suitable. While circular frames with tensioned thin wires and the hybrid frame are more useful in fractures involving the proximal and distal tibia because these frames can provide stable fixation close to a joint without any damage to the joint movement. Application of a pinless fixator is possible as a temporary device if intramedullary nailing is planned at a later stage.

Moreover, a surgeon can customize a device for external fixation to meet the requirement so that stability can be increased. Various options for customizing a device are:

• by increasing the number of pins.

• by spreading the pins as much as possible.

• by reducing the distance between bar and bone.

• by adding a second frame to achieve a V-construct.

• by adding one more bar.

Siora Surgicals Pvt. Ltd. is a manufacturer and exporter of orthopedic implants and instruments for over three decades. We have a comprehensive portfolio of trauma products numbering more than two thousand.