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Wheeless' Textbook of Orthopaedics

Wheeless' Textbook of Orthopaedics

C.R. Wheeless MD

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Wheeless' Textbook of Orthopaedics

Tibia Fractures: Ilizarov / Circular Wire Fixators:

- See: - Ilizarov Menu: - Ring characteristics: - Safe Zone of Pin Insertion: - Foot Inclusion: - Synthes Hybrid Fixator - Wire Insertion Technique - PreOp: - Exam: - knee ligament injuries: - skin abrasions / open fracture - distal sensation and pulses (check dp while compressing pt and vice versa); - consider compartment syndrome - ankle range of motion; - Radiographs: - length of space between tibial plateau and fracture; - length of fracture; - length of space between fracture and tibial plafond; - associated fibular fractures; - Templating: - use opposite normal extemity to help template ring sizes; - two finger breadths of clearances are required; - more space is required posteriorly than anteriorly; - space between inner rings must be > length of fracture comminution - assess potential for transfibular wires (contra w/ fractures) - w/ open or distal frx consider need for foot inclusion; - Frame Construction: - in most cases, the frame should be inserted preoperatively to save time; - two half rings are selected that are 2-3 cm larger than the major diameter of the injured limb (less space is needed anterior to the tibia); - the rings are positioned in the same plane and a bolt and nut anchor together both ends of the half rings; - typically, a 4 ring assembly in required w/ 2 rings proximal and distal to frx site; - most proximal ring in tibial mounting can be open section ring attached to complete ring, allowing maximum flexion & providing two levels of fixation; - two rings are used on large frags, & ring & drop post used for smaller fragments; - two proximal & distal rings are connected via two telescoping rods of appropriate length (the inner rings must span frx comminution); - threaded rods: - initially, only a single long anterior and posterior threaded rod is used to connect the rings together; - this leaves plenty of space medially and laterally for insertion of wires and half pins; - once fixation is complete, two additional threaded rods can be placed; - Frame Construction - Proximal Fractures: - a 5/8 ring can be mounted on top of a complete ring; - the 5/8 ring can be positioned just below the joint line, but will still allow knee flexion; - Frame Construction - Distal Fractures: - w/ minimal plafond displacement, 3 sets of wires & rings are used: - one just above the plafond, the other in proximal tibia, and third through the os calcis. - some distraction is possible between 2 distal rings, and reduction of metaphyseal fragments is facilitated by application of tension to wires with stop nuts; - Surgical Stratedgy: - preliminary reduction of fracture; - insertion of transverse proximal and distal wires wires perpendicular to the knee and ankle joint lines; - application of frame; - tensioning of proximal and distal wires; - frame brought to the wires (wires are not brought to the frame); - this achieves partial reduction in the coronal plane and helps to suspend the leg in the middle of the frames; - application of distraction across the fracture site if shortening is present; - Surgical Technique: - positioning: - supine position, hip bump, and flouro on opposite side of table; - reduction: - traction will usually achieve an approximate reduction; - use Russe method to ensure proper rotation (tubercle to bi-malleolar axis); - application of frame: - open the frame on one side (like a book) and place around the leg; - coupling bolts are aligned parallel to the crest of tibia; - ensure that there is proper clearance with at least one fingerbreadth of space anteriorly and two finger breadth of clearance posteriorly; - too much clearance, however, dramatically reduces the stiffness of the construct; - the leg can be suspended within the rings by using suction tubing tied across the bottom of the leg and over the top of the ring; - coronal wires and frame attachement: - see: safe zone of pin insertion and wires insertion techniques: - proximal coronal plane reference wire: - wire is placed at level of & parallel to knee joint and marked; - a wire is then placed approx one cm below joint line and marked; - distal coronal plane wire: - is placed prior to the remaining proximal wires; - a wire is placed transverse to ankle joint and marked; - the distal wire is driven across the fracture site; - frame attachment: frame is attached to the proximal and distal wires; - mid-shaft wires: - w/ residual displacement at the frx site, olive wires can be inserted on opposite sides of the frx and are tensioned until frx reduction is achieved; - remaining proximal wires: - medial face wire: - inserted from posteromedial side of tibia to antero- lateral side; - flexing the knee may help avoid the pes anserinus; - transfibular - is driven across tibia to exit on anteromedial surface; - ensure that this wire is not too distal so as to have the drop post encroach on the fracture site; - remaining distal wires: - see: safe zones and wires insertion techniques: - ensure that there is proper rotational alignment; - ensure that rings remain centralized; - ensure that the fracture is reduced; - use the Russe method to measure the bi-malleolar axis (measured off the tubercle) on the normal leg to help judge rotation off the fractured leg; - remaining wires: are attached to remaining rings; - half pins: half pins are attached to appropriate rings; - Post Op: - calcaneal wires are removed at six weeks, & ROM exercises are started; - in cases w/ severe articular comminution, proceed w/ second stage at about 15 days when the soft tissues were healed; Limb Reconstruction by Free-Tissue Transfer Combined With the Ilizarov Method. Tibial fractures. The Ilizarov alternative.

Tibia Fractures: Ilizarov / Circular Wire Fixators:

- See: - Ilizarov Menu: - Ring characteristics: - Safe Zone of Pin Insertion: - Foot Inclusion: - Synthes Hybrid Fixator - Wire Insertion Technique - PreOp: - Exam: - knee ligament injuries: - skin abrasions / open fracture - distal sensation and pulses (check dp while compressing pt and vice versa); - consider compartment syndrome - ankle range of motion; - Radiographs: - length of space between tibial plateau and fracture; - length of fracture; - length of space between fracture and tibial plafond; - associated fibular fractures; - Templating: - use opposite normal extemity to help template ring sizes; - two finger breadths of clearances are required; - more space is required posteriorly than anteriorly; - space between inner rings must be > length of fracture comminution - assess potential for transfibular wires (contra w/ fractures) - w/ open or distal frx consider need for foot inclusion; - Frame Construction: - in most cases, the frame should be inserted preoperatively to save time; - two half rings are selected that are 2-3 cm larger than the major diameter of the injured limb (less space is needed anterior to the tibia); - the rings are positioned in the same plane and a bolt and nut anchor together both ends of the half rings; - typically, a 4 ring assembly in required w/ 2 rings proximal and distal to frx site; - most proximal ring in tibial mounting can be open section ring attached to complete ring, allowing maximum flexion & providing two levels of fixation; - two rings are used on large frags, & ring & drop post used for smaller fragments; - two proximal & distal rings are connected via two telescoping rods of appropriate length (the inner rings must span frx comminution); - threaded rods: - initially, only a single long anterior and posterior threaded rod is used to connect the rings together; - this leaves plenty of space medially and laterally for insertion of wires and half pins; - once fixation is complete, two additional threaded rods can be placed; - Frame Construction - Proximal Fractures: - a 5/8 ring can be mounted on top of a complete ring; - the 5/8 ring can be positioned just below the joint line, but will still allow knee flexion; - Frame Construction - Distal Fractures: - w/ minimal plafond displacement, 3 sets of wires & rings are used: - one just above the plafond, the other in proximal tibia, and third through the os calcis. - some distraction is possible between 2 distal rings, and reduction of metaphyseal fragments is facilitated by application of tension to wires with stop nuts; - Surgical Stratedgy: - preliminary reduction of fracture; - insertion of transverse proximal and distal wires wires perpendicular to the knee and ankle joint lines; - application of frame; - tensioning of proximal and distal wires; - frame brought to the wires (wires are not brought to the frame); - this achieves partial reduction in the coronal plane and helps to suspend the leg in the middle of the frames; - application of distraction across the fracture site if shortening is present; - Surgical Technique: - positioning: - supine position, hip bump, and flouro on opposite side of table; - reduction: - traction will usually achieve an approximate reduction; - use Russe method to ensure proper rotation (tubercle to bi-malleolar axis); - application of frame: - open the frame on one side (like a book) and place around the leg; - coupling bolts are aligned parallel to the crest of tibia; - ensure that there is proper clearance with at least one fingerbreadth of space anteriorly and two finger breadth of clearance posteriorly; - too much clearance, however, dramatically reduces the stiffness of the construct; - the leg can be suspended within the rings by using suction tubing tied across the bottom of the leg and over the top of the ring; - coronal wires and frame attachement: - see: safe zone of pin insertion and wires insertion techniques: - proximal coronal plane reference wire: - wire is placed at level of & parallel to knee joint and marked; - a wire is then placed approx one cm below joint line and marked; - distal coronal plane wire: - is placed prior to the remaining proximal wires; - a wire is placed transverse to ankle joint and marked; - the distal wire is driven across the fracture site; - frame attachment: frame is attached to the proximal and distal wires; - mid-shaft wires: - w/ residual displacement at the frx site, olive wires can be inserted on opposite sides of the frx and are tensioned until frx reduction is achieved; - remaining proximal wires: - medial face wire: - inserted from posteromedial side of tibia to antero- lateral side; - flexing the knee may help avoid the pes anserinus; - transfibular - is driven across tibia to exit on anteromedial surface; - ensure that this wire is not too distal so as to have the drop post encroach on the fracture site; - remaining distal wires: - see: safe zones and wires insertion techniques: - ensure that there is proper rotational alignment; - ensure that rings remain centralized; - ensure that the fracture is reduced; - use the Russe method to measure the bi-malleolar axis (measured off the tubercle) on the normal leg to help judge rotation off the fractured leg; - remaining wires: are attached to remaining rings; - half pins: half pins are attached to appropriate rings; - Post Op: - calcaneal wires are removed at six weeks, & ROM exercises are started; - in cases w/ severe articular comminution, proceed w/ second stage at about 15 days when the soft tissues were healed; Limb Reconstruction by Free-Tissue Transfer Combined With the Ilizarov Method. Tibial fractures. The Ilizarov alternative.
 
 
 
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