Fine-Wire Fixator

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SAMPLE EXCERPT
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PRE-PROCEDURE
INDICATIONS
  • Intramedullary fixation
    • Tibial shaft fracture from high-energy trauma
    • Failure to maintain fracture alignment
    • Most open fractures
    • Fractures with severe closed soft-tissue injury
    • Fractures with associated compartment syndrome
    • Fractures with associated vascular injury
    • Fractures in patients with multiple trauma
    • Segmental fractures with a displaced central fragment
    • Bilateral tibial shaft fractures
    • Tibial shaft fractures with associated ipsilateral femoral fractures
  • External fixation
    • Severe open fractures (types IIIB and IIIC)
    • Fractures with severe contamination of the tibial canal
    • Open fractures receiving delayed (>24 hours) treatment
    • Open fractures (including those from gunshot wounds or crush injuries) in which the adequacy of the initial debridement is in question
    • Tibial fractures with periarticular extension
    • Delayed management of fractures with bone loss
    • Fractures in patients with a very small medullary canal
    • Fractures in patients with skin lesions (e.g., burns) over tibial nail entry site
    • Associated vascular injury when salvage is questionable
    • Polytrauma patient when blood loss must be kept to a minimum (e.g., Jehovah's Witnesses)
    • Temporary fixation before definitive open treatment
CONTRAINDICATIONS
  • Young patients with open physes
  • Anatomic deformity
  • Burns or other skin wound over the entry portal
  • Most type IIIC open fractures
EQUIPMENT
  • Fracture table
  • Traction apparatus
  • Fluoroscopy unit
  • Femoral distractor or two-pin external fixator
  • Schanz pins
  • Curved awl
  • Kirschner wires
  • Rigid reamer
  • Ball-tipped guidewire
  • Drill
  • Sounds and reamers
  • Radiopaque ruler
  • Intramedullary nail
  • Locking screws
  • Fine-wire external fixator
ANATOMY
  • The tibial shaft is triangular and narrowest at the junction between the middle and distal thirds.
  • The tibia is surrounded by four compartments of muscles: anterior, lateral, superficial posterior, and deep posterior.
    • Anterior compartment: tibialis anterior muscle, extensor digitorum muscle, extensor hallucis longus muscle, the anterior tibial artery, and the deep peroneal nerve
    • Lateral compartment: peroneus longus and peroneus brevis muscles and superficial peroneal nerve
    • Superficial posterior compartment: soleus, gastrocnemius, and plantaris muscles
    • Deep posterior compartment: flexor digitorum longus muscle, tibialis posterior muscle, flexor hallucis longus muscle, the posterior tibial artery and nerve, and the peroneal artery and nerve

PROCEDURE
Sample excerpt does not include step-by-step text instructions for performing this procedure
The full content of this section includes:
  • Step-by-step text instructions for performing the procedure
  • Clinical pearls providing practical clinical tips from medical experts
  • Patient safety guidelines consistent with Joint Commission and OHSA standards
  • Links to medical evidence and related procedures

POST-PROCEDURE
TECHNIQUES
  • Post-Procedure: Intramedullary Interlocking Nails
  • Post-Procedure: Fine-Wire Fixation

Post-Procedure: Intramedullary Interlocking Nails

POST-PROCEDURE CARE
  • IM nailing: apply removable splint with a patellar tendon-bearing brace or orthosis if additional support is needed.
  • External fixator: instruct patients on careful pin site care.
  • Therapy: begin knee and hip range-of-motion and isometric quadriceps exercises.
  • Weight-bearing: restrict for 4 to 6 weeks and then progress as tolerated.
  • Fixator removal: if the foot was included, remove the foot pins when soft-tissue healing is adequate. Delay this if there is an unstable ankle injury. Monitor healing and pin sites every 4 to 6 weeks.
  • Nail removal: usually not necessary; delay until 12 to 18 months if symptomatic.
COMPLICATIONS
  • Compartment syndrome
  • Neurovascular injury
  • Delayed union or nonunion
  • Infection
  • Hardware failure
ANALYSIS OF RESULTS

Intramedullary nailing for tibial shaft fractures has been shown to have excellent success with a high union rate and low complication rate. The most common complication has been infection, which most frequently occurs in severely comminuted open fractures.

OUTCOMES AND EVIDENCE
  • Bone et al compared IM nailing with casting and found significantly fewer nonunions in the IM nailing group. The casting group had significantly higher rates of malalignment and fracture shortening.
  • Puno et al also compared IM nailing with closed reduction and casting. The IM nailing group had 98% union, 3.3% infection, and no malalignment. The casted group had 90.1% union, 1.4% infection, and 4.5% malalignment.
  • Hooper et al found significantly better outcomes with IM nailing than with casting for closed or grade I open tibial fractures with at least 50% displacement or 10 degrees of angulation.
  • Klemm and Borner reported 94% excellent to good results with interlocking IM nails with an infection rate of 2.2%.
  • Keating et al found no statistically significant differences in outcomes with reamed or unreamed nailing for open fractures but found a higher rate of screw breakage in the unreamed group.
  • Ali et al: good to excellent results in 85% of complex proximal tibial fractures treated with beam-loading ring fixation
  • Roberts et al compared commonly used hybrid and ring fixators and showed that the most common error in all systems is undertensioning.
  • Adair et al reported that Ilizarov complication rate was 34%, with 6.6% infection, 14% malunion or nonunion, 4% nerve injury, 6.9% joint stiffness, 0.3% patient depression, 1% pain requiring referral to pain management, and 1% wire breakage.
Procedure: Intramedullary Interlocking Nails

Post-Procedure: Fine-Wire Fixation

POST-PROCEDURE CARE
  • IM nailing: apply removable splint with a patellar tendon-bearing brace or orthosis if additional support is needed.
  • External fixator: instruct patients on careful pin site care.
  • Therapy: begin knee and hip range-of-motion and isometric quadriceps exercises.
  • Weight-bearing: restrict for 4 to 6 weeks and then progress as tolerated.
  • Fixator removal: if the foot was included, remove the foot pins when soft-tissue healing is adequate. Delay this if there is an unstable ankle injury. Monitor healing and pin sites every 4 to 6 weeks.
  • Nail removal: usually not necessary; delay until 12 to 18 months if symptomatic.
COMPLICATIONS
  • Compartment syndrome
  • Neurovascular injury
  • Delayed union or nonunion
  • Infection
  • Hardware failure
ANALYSIS OF RESULTS

Intramedullary nailing for tibial shaft fractures has been shown to have excellent success with a high union rate and low complication rate. The most common complication has been infection, which most frequently occurs in severely comminuted open fractures.

OUTCOMES AND EVIDENCE
  • Bone et al compared IM nailing with casting and found significantly fewer nonunions in the IM nailing group. The casting group had significantly higher rates of malalignment and fracture shortening.
  • Puno et al also compared IM nailing with closed reduction and casting. The IM nailing group had 98% union, 3.3% infection, and no malalignment. The casted group had 90.1% union, 1.4% infection, and 4.5% malalignment.
  • Hooper et al found significantly better outcomes with IM nailing than with casting for closed or grade I open tibial fractures with at least 50% displacement or 10 degrees of angulation.
  • Klemm and Borner reported 94% excellent to good results with interlocking IM nails with an infection rate of 2.2%.
  • Keating et al found no statistically significant differences in outcomes with reamed or unreamed nailing for open fractures but found a higher rate of screw breakage in the unreamed group.
  • Ali et al: good to excellent results in 85% of complex proximal tibial fractures treated with beam-loading ring fixation
  • Roberts et al compared commonly used hybrid and ring fixators and showed that the most common error in all systems is undertensioning.
  • Adair et al reported that Ilizarov complication rate was 34%, with 6.6% infection, 14% malunion or nonunion, 4% nerve injury, 6.9% joint stiffness, 0.3% patient depression, 1% pain requiring referral to pain management, and 1% wire breakage.
Procedure: Fine-Wire Fixation
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