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Wheeless' Textbook of Orthopaedics

Wheeless' Textbook of Orthopaedics

C.R. Wheeless MD

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Wheeless' Textbook of Orthopaedics

Safe Zone of Pin Insertion for Ex Fix:

- Proximal to the Tibial Tubercle: - pins can safely be inserted within an arc of 220 deg; - safe zone extends from posteromedial border of tibial plateau to the tibiofibular joint (of course, this excludes the patellar tendon); - halfpins: are inserted at the oblique lateral aspect of proximal tibia; - transfixation wires: - can be inserted transversely, anterior to MCL and head of fibula; - can be inserted thru anterior portion of fibular head, across proximal tibia, to exit medial to the patellar tendon; - hazards: - all neurovascular structures are located posterior to fibular head and the MCL; - because the synovial recess extends below the joint line, wires should be placed at least 1 cm below joint line to avoid potential septic arthritis; - further, w/ tibial plateau frx, disruption of the joint capsule will mean that even pins placed 2-3 cm from the joint, will be ask risk for septic arthritis; - you only need to see one of these to believe it; - Just Distal to the Tibial Tubercle: - safe arc of insertion is decreased to 140 deg, and this level is not entirely safe for transfixion wires; - anterior tibial artery is located just anterior to interosseous membrane, and the posterior tibial artery lies behind the tibialis posterior; - therefore, transfibular transfixation pins cannot be inserted at this level; - posteriorly directed pins are to be especially avoided; - halfpins: - are inserted at the oblique medial aspect of tibia; - transfixation wires: - are inserted at the oblique lateral aspect of tiba (thru tibialis anterior) and exits along the postero-medial aspect of tibia; - Mid-Tibia and Distal Tibia: - same as above; - along the distal tibia, the anterior tibial vessels hug the medial tibial cortex; - Distal Tibia (above the ankle): - safe arc remains at 120-140 deg, but anterior tibial vessels and deep peroneal nerves become vulnerable as they cross the lateral tibial cortex; - transfixation wires: - transfibular fixation wire: placed thru anterior portion of fibula (to avoid the peroneal vessels); - transverse fixation wire: avoid transfixation of the saphenous nerve and vein; - Foot Inclusion: ----------------------------- (Behren, F. and Searls, K.: JBJS (Br) 68: 246-254, 1986)

Safe Zone of Pin Insertion for Ex Fix:

- Proximal to the Tibial Tubercle: - pins can safely be inserted within an arc of 220 deg; - safe zone extends from posteromedial border of tibial plateau to the tibiofibular joint (of course, this excludes the patellar tendon); - halfpins: are inserted at the oblique lateral aspect of proximal tibia; - transfixation wires: - can be inserted transversely, anterior to MCL and head of fibula; - can be inserted thru anterior portion of fibular head, across proximal tibia, to exit medial to the patellar tendon; - hazards: - all neurovascular structures are located posterior to fibular head and the MCL; - because the synovial recess extends below the joint line, wires should be placed at least 1 cm below joint line to avoid potential septic arthritis; - further, w/ tibial plateau frx, disruption of the joint capsule will mean that even pins placed 2-3 cm from the joint, will be ask risk for septic arthritis; - you only need to see one of these to believe it; - Just Distal to the Tibial Tubercle: - safe arc of insertion is decreased to 140 deg, and this level is not entirely safe for transfixion wires; - anterior tibial artery is located just anterior to interosseous membrane, and the posterior tibial artery lies behind the tibialis posterior; - therefore, transfibular transfixation pins cannot be inserted at this level; - posteriorly directed pins are to be especially avoided; - halfpins: - are inserted at the oblique medial aspect of tibia; - transfixation wires: - are inserted at the oblique lateral aspect of tiba (thru tibialis anterior) and exits along the postero-medial aspect of tibia; - Mid-Tibia and Distal Tibia: - same as above; - along the distal tibia, the anterior tibial vessels hug the medial tibial cortex; - Distal Tibia (above the ankle): - safe arc remains at 120-140 deg, but anterior tibial vessels and deep peroneal nerves become vulnerable as they cross the lateral tibial cortex; - transfixation wires: - transfibular fixation wire: placed thru anterior portion of fibula (to avoid the peroneal vessels); - transverse fixation wire: avoid transfixation of the saphenous nerve and vein; - Foot Inclusion: ----------------------------- (Behren, F. and Searls, K.: JBJS (Br) 68: 246-254, 1986)
 
 
 
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