What is the treatment protocol for a fracture of the distal tibia and fibula treated with an external fixator?

From the Guidelines

The treatment protocol for a distal tibia and fibula fracture using an external fixator begins with initial stabilization, followed by definitive fixation, and should be performed within the first 24 hours to reduce morbidity and mortality, as recommended by the most recent guidelines 1.

Pre-Operative Care

Before surgery, the patient receives prophylactic antibiotics, typically cefazolin 1-2g IV, to prevent infection. Initial assessment and imaging are crucial to determine the extent of the fracture and plan the surgical approach.

Surgical Procedure

The external fixator application involves placing pins proximal to the fracture in the tibial shaft and distal to the fracture in the calcaneus or metatarsals, connected by external bars. This approach provides fracture stability while allowing soft tissue management, particularly important in open fractures or those with significant swelling.

Post-Operative Care

Post-operatively, patients require regular pin site care using chlorhexidine or normal saline twice daily to prevent infection. Weight-bearing status typically progresses from non-weight bearing for 6-8 weeks to partial weight bearing as healing progresses, based on radiographic evidence of callus formation. Pain management includes scheduled acetaminophen (1000mg every 6 hours), NSAIDs like ibuprofen (600mg every 6 hours) if not contraindicated, and short-term opioids as needed.

Rehabilitation and Follow-Up

Physical therapy should begin early with ankle and knee range of motion exercises to prevent stiffness. The external fixator remains in place for 12-16 weeks until sufficient healing occurs, with regular follow-up radiographs every 2-4 weeks to assess healing. The most recent study on surgical treatment of fractures recommends a combined approach of external fixation with intramedullary fixation to prevent refractures and axial deformities 1.

Key Considerations

• Fracture stability is crucial for bone consolidation and eradication of infection 1.
• The presence of a foreign body increases the risk of infection, but the advantage of implants for stabilization outweighs their increased susceptibility to infection 1.
• A delayed definitive osteosynthesis of diaphyseal fractures is probably recommended within the first 24h to reduce the incidence of systemic complications related to surgical hit, perioperative blood loss, coagulopathy or fat embolism syndrome 1.

Summary of Recommendations

• Perform external fixator application within the first 24 hours to reduce morbidity and mortality.
• Use prophylactic antibiotics to prevent infection.
• Provide regular pin site care and progress weight-bearing status as healing progresses.
• Begin early physical therapy to prevent stiffness.
• Consider a combined approach of external fixation with intramedullary fixation to prevent refractures and axial deformities.

From the Research

Procedure for Fracture Distal Tibia Fibula by External Fixator

The treatment protocol for a fracture of the distal tibia and fibula treated with an external fixator involves several steps:

• Preoperative preparation: The patient is prepared for surgery, and the affected limb is cleaned and draped in a sterile manner.
• Application of external fixator: The external fixator is applied to the affected limb, with pins or wires inserted into the bone to stabilize the fracture 2, 3.
• Reduction of fracture: The fracture is reduced, and the bones are aligned properly.
• Fixation of fibula: The fibula may or may not be fixed, depending on the type of fracture and the surgeon's preference 4, 5.
• Postoperative care: The patient is monitored for any complications, and the affected limb is immobilized to allow for healing.
• Follow-up: The patient is followed up regularly to assess the healing progress and to remove the external fixator once the fracture has healed 6.

Types of External Fixators

There are different types of external fixators that can be used to treat distal tibia and fibula fractures, including:

• Circular external fixator: This type of fixator is used to treat complex fractures and provides stability and support to the affected limb 2.
• Hybrid external fixator: This type of fixator is used to treat fractures that require both internal and external fixation 3.
• Unilateral external fixator: This type of fixator is used to treat fractures with poor soft tissue conditions and provides stability and support to the affected limb 6.

Fixation of Fibula

The fixation of the fibula is a controversial topic, and the decision to fix or not to fix the fibula depends on the type of fracture and the surgeon's preference 5. Some studies suggest that fibular fixation is necessary in certain types of fractures, while others suggest that it is not necessary 4, 5.

Complications

The use of external fixators to treat distal tibia and fibula fractures can be associated with several complications, including:

• Pin-tract infection: This is a common complication of external fixator use and can be treated with antibiotics and pin-tract care 3, 6.
• Delayed union or nonunion: This can occur if the fracture does not heal properly, and may require additional treatment, such as bone grafting or revision surgery 2, 4.
• Malunion or malalignment: This can occur if the fracture is not properly reduced or if the external fixator is not applied correctly 2, 3.