Minimal internal fixation of tibial fractures

Flexible wire and small pins cause minimal disturbance of osseous blood supply, and introduce minimal foreign material into the wound. Supplemental support by a plaster cast or by traction is required, but the external support can generally be discontinued early for joint mobilization. Several simple auxillary fixation devices extend the usefulness of wire fixation. Removal of metal is not required. Many common fractures of the tibia are amenable to this method of minimal internal fixation. In the diaphysis, long oblique fractures are the most suitable for this application; the firmness of their fixation by cerclage is augmented by muscle pull. Rotation is effectively controlled by a plate which is L-shaped in cross section, and is held in position by cerclage. In the metaphysis, articular fractures of the knee and ankle are securely fixed by a flattened loop of wire and two washers (wire-washer set), supplemented sometimes by pins or hand-made staples. Two pins alone provide excellent fixation of the medial malleolus. A single pin, or a single wire loop through drill holes, may be sufficient to impart stability to an unstable tibial fracture. A key-type graft of iliac bone, maintained by crossed wire loops through cortical drill holes, is effective in the tibial diaphysis. Autogenous iliac cancellous chips provide minimal and effective internal fixation for an infected ununited fracture of the tibia. The surgical instrument most important for making wire fixation highly successful is a tightener-twister which protects wire loops from excessive strain during application, and permits twisting at a predetermined and therefore reproducible tension. Other special and ordinary instruments are valuable assets.