Wheeless' Textbook of Orthopaedics
C.R. Wheeless MD
Wheeless' Textbook of Orthopaedics
- 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)
- 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)