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This skills module allows medical officers and surgeons who are not orthopedic specialists to become confident and competent in performing irrigation and debridement, power and manual drilling, proper positioning and insertion of Schanz screws, construction of the uniplanar frame, and fracture reduction and stabilization as part of external fixation procedures for open tibial shaft fractures performed in regions without specialist coverage. To maximize patient safety, this module teaches learners to use a powered drill to insert self-drilling Schanz screws through the near cortex and then manually advance Schanz screws into the far cortex to avoid plunging.

Learning Objectives

Training Objectives

By the end of this module, learners will be able to perform the following procedural steps:

1. Perform irrigation using an average of 3L of irrigation solution for each successive Gustilo Type (i.e., 6L for Gustilo Type II open tibial fracture and 9L for Gustilo Type III open tibial fracture) to reduce the risk of infection.*[1][2][3]

2. Debride all foreign material and non-viable tissue to reduce the risk of infection and minimize wound complications.*[3][4]

3. Extend the open wound, if necessary, to directly visualize the fracture.*

4. While directly visualizing the fracture, apply manual longitudinal traction to the distal lower extremity to reduce the fracture.*

5. Use bone reduction forceps to manually reduce the fracture, compress the fragments together, and restore alignment:

  • Bone apposition > 50%[5]
  • Rotation < 10 degrees[5][6][7]
  • Angulation < 10 degrees in any plane[6][8][9]
  • Length discrepancy < 2 cm shortening[6]
  • No distraction (lengthening)[7]

6. Confirm restoration of rotational alignment by visually checking the position of the big toe and the alignment of the middle of the second toe with the center of the patella.*[10]

7. Palpate the medial malleolus of both limbs under sterile conditions to estimate and compare the length of the reduced limb to the uninjured limb.*[11]

8. If required, adjust the fragments to achieve an alignment within acceptable parameters:

  • Bone apposition > 50%[5]
  • Rotation < 10 degrees[5][6][7]
  • Angulation < 10 degrees in any plane[6][8][9]
  • Length discrepancy < 2 cm shortening[6]
  • No distraction (lengthening)[7]

9. Apply bone holding forceps to maintain the reduced fracture.

10. Position the “far” Schanz screw (furthest from the fracture line) in the proximal fragment medial or distal to the tibial tuberosity while avoiding traumatized soft tissues to avoid tethering of the patellar ligament and penetration into the knee joint.[12]

11. Place the "far" Schanz screw in the distal fragment at least two fingers’ breadth proximal to the medial malleolus while avoiding traumatized soft tissues to avoid entry into the ankle joint.*

12. Position the two "far" Schanz screws as widely apart as possible into each fragment while avoiding traumatized soft tissues and entry into knee and ankle joints to permit better control of displacing forces and optimize stabilization of the reduction.[13][14][15][16]

13. Use a scalpel to make a stab incision into the soft tissue overlying the anteromedial wall of the tibia for each Schanz screw.*[17]

14. Use dissecting scissors to spread the soft tissue apart in each stab incision to expose the bone for drilling.*

15. Prepare the powered surgical drill for use by inserting a Schanz screw into the powered surgical drill, inserting the chuck key into the opening in the drill, turning the chuck key clockwise to tighten the drill over the Schanz screw, and then engaging the switch for forward drilling direction.

16. Test the powered surgical drill is ready for use by pressing the on/off trigger and confirm that the Schanz screw tip is rotating clockwise when the drill is pointing forward.

17. Slide the universal chuck with T-handle over the Schanz screw, and tightened the chuck over the Schanz screw by manually rotating the proximal part of the chuck clockwise or by inserting the chuck key into the opening in the universal chuck with T-handle and turning the chuck key clockwise.

18. Position the drill sleeve directly on the near cortex in each stab incision to protect the surrounding soft tissues when drilling each "far" Schanz screw.*

19. Place each Schanz screw tip directly on the near cortex of the anteromedial tibial wall and not on the anterior tibial crest.

20. Insert both "far" Schanz screws in the proximal and distal fragments using an identical drill trajectory angle between 30°-60° relative to the tibial crest to reduce the risk of damage to neurovascular structures.[18][19]

21. Direct an assistant to perform irrigation while drilling to reduce the risk of thermal osteonecrosis.*[20]

22. Start drilling with the Schanz screw tip rotating in a clockwise direction, and ensure that the tip does not slip on the near cortex which can injure the medial and lateral soft tissues.[17][18]

23. Power drill each Schanz screw through the near cortex of the anteromedial tibial wall and use tactile feel and acoustic feedback to stop drilling after passing through the near cortex and before or when the inner surface of the far cortex is reached to avoid plunging through the far cortex and damaging underlying neurovascular structures and soft tissues.[17][21]

24. Use the chuck key to detach the powered surgical drill from each Schanz screw.

25. Remove the drill sleeve from each "far" Schanz screw.

26. Slide the universal chuck with T-handle over the Schanz screw, and tightened the chuck over the Schanz screw by manually rotating the proximal part of the chuck clockwise or by inserting the chuck key into the opening in the universal chuck with T-handle and turning the chuck key clockwise.

27. Use the universal chuck with T-handle to turn each Schanz screw manually for one to two 360 degree rotations to anchor the screw tip into the far cortex without exiting the far cortex.

28. Detach the universal chuck with T-handle from the Schanz screw by manually rotating the proximal part of the chuck anticlockwise or inserting the chuck key into the small, circular opening in the chuck and turning the chuck key anticlockwise.

29. Insert four pin-to-rod clamps to a 300 mm uniplanar rod.[17]

30. Apply the two outer pin-to-rod clamps to connect the two "far" Schanz screws to the 300 mm uniplanar rod.

31. Tighten the two outer pin-to-rod clamps by hand.

32. Leave the pin opening of the two inner pin-to-rod clamps loosened.

33. Place the two “near” Schanz screws (closest to the fracture line) at least 2.0 cm (a finger breadth) from the fracture line while avoiding traumatized soft tissues to help prevent the placement of the Schanz screw within the fracture hematoma and risk having a pin site infection spread within the fracture.[22][13]

34. Position the "near and far" Schanz screws as widely apart as possible into each fragment while avoiding traumatized soft tissues and entry into knee and ankle joints to permit better control of displacing forces and optimize stabilization of the reduction.[13][14][15][16]

35. Use a scalpel to make a stab incision into the soft tissue overlying the anteromedial wall of the tibia for each "near" Schanz screw.*[17]

36. Use dissecting scissors to spread the soft tissue apart in each stab incision to expose the bone for drilling.*

37. Prepare the powered surgical drill for use by inserting a Schanz screw into the powered surgical drill, inserting the chuck key into the opening in the drill, turning the chuck key clockwise to tighten the drill over the Schanz screw, and then engaging the switch for forward drilling direction.

38. Test the powered surgical drill is ready for use by pressing the on/off trigger and confirm that the Schanz screw tip is rotating clockwise when the drill is pointing forward.

39. Insert each "near" Schanz screw into the loosened pin opening in the rod-to-pin clamp attached to the 300 mm rod.

40. Place each Schanz screw tip directly on the near cortex of the anteromedial tibial wall and not on the anterior tibial crest.

41. Insert both "near" Schanz screws in the proximal and distal fragments at an identical drill trajectory angle to both "far" Schanz screws to reduce the risk of damage to neurovascular structures.[18][19]

42. Direct an assistant to perform irrigation while drilling to reduce the risk of thermal osteonecrosis.*[20]

43. Place the "near" Schanz screw tip on the anteromedial tibial wall, start drilling with the screw tip rotating in a clockwise direction, and ensure that the tip does not slip on the near cortex which can injure the medial and lateral soft tissues.[17][18]

44. Power drill each Schanz screw through the near cortex of the anteromedial tibial wall and use tactile feel and acoustic feedback to stop drilling after passing through the near cortex and before or when the inner surface of the far cortex is reached to avoid plunging through the far cortex and damaging underlying neurovascular structures and soft tissues.[17][21]

45. Use the chuck key to detach the powered surgical drill from each Schanz screw.

46. Slide the universal chuck with T-handle over the Schanz screw, and tightened the chuck over the Schanz screw by manually rotating the proximal part of the chuck clockwise or by inserting the chuck key into the opening in the universal chuck with T-handle and turning the chuck key clockwise.

47. Use the universal chuck with T-handle to turn each "near" Schanz screw manually for one to two 360 degree rotations to anchor the screw tip into the far cortex without exiting the far cortex.

48. Detach the universal chuck with T-handle from the Schanz screw by manually rotating the proximal part of the chuck anticlockwise or inserting the chuck key into the small, circular opening in the chuck and turning the chuck key anticlockwise.

49. Apply and turn the 11 mm spanner with T-handle wrench clockwise for final tightening of the pin-to-rod clamps.

50. Verify the reduction visually, and with gentle palpation of the tibial crest at the fracture line to confirm that the alignment is still within acceptable parameters:

  • Bone apposition > 50%[5]
  • Rotation < 10 degrees[5][6][7]
  • Angulation < 10 degrees in any plane[6][8][9]
  • Length discrepancy < 2 cm shortening[6]
  • No distraction (lengthening)[7]

51. Confirm restoration of rotational alignment by visually checking the position of the big toe and the alignment of the middle of the second toe with the center of the patella.*[10]

52. Palpate the medial malleolus of both limbs under sterile conditions to estimate and compare the length of the reduced limb to the uninjured limb.*[11]

53. Remove the bone holding forceps once fracture is stabilized with external fixator frame and acceptable alignment is confirmed.*

54. Inspect the pin sites for skin tenting and if present, the stab incision should be widened to release any soft tissue tension around the pin site to reduce the risk of inflammation and pin infection.*[23]

55. Clean the extremity and apply sterile gauze dressings to all four pin sites at the end of the procedure.*

56. Use a measuring tape to measure and compare the limb length (from the anterior superior iliac spine to the medial malleolus) of both legs to confirm acceptable length discrepancy in the injured leg after dressings have been applied.*[11]

57. Re-evaluate the Gustilo open-fracture classification for the open tibial fracture in the operating room, and update the antibiotic regimen and surgical treatment plan accordingly.*[3][24][25][26][27][28]

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The steps above highlighted with an asterix (*) cannot be performed during simulation training but must be performed during the actual clinical procedure.

Knowledge Objectives

By the end of the module, the learner should know to perform the following steps in the actual clinical procedure:

1. Irrigate a Gustilo Type II open tibial shaft fracture with an average of 6 L of irrigation solution and Gustilo Type III open tibial shaft fracture with an average of 9 L of irrigation solution to reduce the risk of osteomyelitis.

2. Debride all foreign material and non-viable tissue to reduce the risk of infection and minimize wound complications.

3. Extend the open wound, if necessary, to directly visualize the fracture.

4. While directly visualizing the fracture, apply manual longitudinal traction to the distal lower extremity to reduce the fracture.

5. Confirm restoration of rotational alignment by visually checking the position of the big toe and the alignment of the middle of the second toe with the center of patella.

6. Palpate the medial malleolus of both limbs under sterile conditions to estimate and compare the length of the reduced limb to the uninjured limb to confirm acceptable length discrepancy in the injured leg.

7. Use a scalpel to make a stab incision in the soft tissue overlying the anteromedial tibial wall for each Schanz screw.[17]

8. Used dissecting scissors to spread the soft tissue in each stab incision to expose the bone for drilling.

9. Position the far Schanz screw in the distal fragment at least two fingers’ breadth proximal to the medial malleolus while avoiding traumatized soft tissues to avoid penetration into the ankle joint.

10. Position the drill sleeve directly on the near cortex in each stab incision to protect the surrounding soft tissues when drilling each "far" Schanz screw.

11. Direct an assistant to provide irrigation while drilling is performed to reduce the risk of thermal osteonecrosis.[20]

12. Remove the bone holding forceps once fracture is stabilized with external fixator frame and acceptable alignment is confirmed.

13. Inspect the pin sites for skin tenting and if present, the stab incision should be widened to release any soft tissue tension around the pin site to reduce the risk of inflammation and pin infection.

14. Clean the extremity and apply sterile gauze dressings to all 4 pin sites at the end of the procedure.

15. Use a measuring tape to measure and compare the limb length (from the anterior superior iliac spine to the medial malleolus) of both legs to confirm acceptable length discrepancy in the injured leg after dressings have been applied.

16. Re-evaluate the Gustilo open-fracture classification for the open tibial fracture in the operating room, and update the antibiotic regimen and surgical treatment plan accordingly.

Materials and Equipment

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Uniplanar External Fixation Hardware Courtesy of Medical Aid International and Dr. Habila Umaru
Uniplanar External Fixation Hardware
  • Bone reduction forceps
  • Bone holding forceps, medium size
  • 300 mm rod, 11 mm diameter for clamps designed for 5.0 mm Schanz screws
  • Pin-to-rod clamps for 11 mm diameter rods and 5.0 mm Schanz screws, Quantity: 4
  • Self-drilling Schanz screws, 5.0 mm diameter, Quantity: 4
  • Chuck key for universal chuck with T-handle T-Handle
  • Universal chuck with T-handle for 5.0 mm Schanz screws
  • 11 mm spanner with T-handle wrench
  • Drill sleeve, properly sized for 5.0 mm Schanz screws (not shown)
2
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Surgical Supplies
Surgical Supplies
  • Eye protection
  • Gloves
  • 50 mL syringe*
  • Scalpel handle with 22 blade*
  • Dissecting scissors*
  • Chuck key
  • Any powered surgical drill compatible with 5.0 mm diameter self-drilling Schanz screws
  • Measuring tape*
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The items above highlighted with an asterix (*) are not used in this simulation training but are used during the actual clinical procedure.

3
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Tibial Shaft Transverse Fracture Simulator Secured In Vise Clamps
Tibial Shaft Transverse Fracture Simulator
The vise clamps securing the Tibial Shaft Transverse Fracture Simulator will be positioned so the fracture ends are slightly distracted by 2.0 to 3.0 mm.
4
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Self-Assessment Framework Supplies
Self-Assessment Framework Supplies
  • Scissors
  • Ruler
  • Protractor
  • Clipboard
  • Training Logbook
  • Pen
  • Any cellphone with a camera

Training Logbook

Please go to this link to print out the Training Logbook.

Procedure Steps

{{#evt:service=youtube|id=YVmySxafeCM|urlargs=enablejsapi=1&rel=0&origin=https://www.appropedia.org}}
Annotations:
  • 00:00 Loosen Right Vise Clamp Securing Distal Fragment to Simulate a Displaced Fracture
  • 00:09 Irrigate and Debride Open Wounds
  • 00:17 Use Bone Reduction Forceps to Manually Reduce Fracture Note: It May Be Necessary To Extend the Wound to Directly Visualize the Fracture
  • 00:28 Apply Bone Holding Forceps to Maintain Reduction
  • 00:44 Tighten Right Vise Clamp and Remove Bone Reduction Forceps Once Fracture is Stabilized
  • 01:01 Position Far Schanz Screw in Proximal Fragment Medial or Distal to the Tibial Tuberosity
  • 01:17 Power Drill Far Schanz Screw Into Proximal Fragment at a Drill Trajectory Angle Between 30 - 60 Degrees
  • 01:51 Manually Advance Far Schanz Screw Into Far Cortex of Proximal Fragment
  • 02:18 Position Far Schanz Screw in Distal Fragment At Least Two Fingers' Breadth Proximal to the Medial Malleolus (Not Shown)
  • 02:36 Power Drill Far Schanz Screw Into Distal Fragment At Identical Drill Trajectory Angle to Other Schanz Screw
  • 03:12 Manually Advance Far Schanz Screw Into Far Cortex of Distal Fragment
  • 03:34 Use Pin-To-Rod Clamps to Attach Uniplanar Rod to Both Far Schanz Screws
  • 03:45 Position Near Schanz Screw in Distal Fragment At Least 2 cm From the Fracture Line
  • 03:59 Power Drill Near Schanz Screw in Distal Fragment At Identical Drill Trajectory Angle to Other Schanz Screws
  • 04:29 Manually Advance Near Schanz Screw Into Far Cortex of Distal Fragment
  • 04:53 Position Near Schanz Screw in Proximal Fragment At Least 2 cm From the Fracture Line
  • 05:08 Power Drill Near Schanz Screw in Proximal Fragment At Identical Drill Trajectory Angle to Other Schanz Screws
  • 05:34 Manually Advance Near Schanz Screw Into Far Cortex of Proximal Fragment
  • 05:59 Stabilize and Inspect Reduced Fracture
  • 06:51 Remove Bone Holding Forceps
  • 06:59 Confirm Adequate Reduction

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The bulleted steps below highlighted in bold and with an asterix (*) are considered as critical for the procedure and for which only essential conversations and activities in the operating room should occur to avoid distracting the surgical practitioner from their performance of his or her duties.[29]

1
Irrigate and Debride Open Wounds

1. Start this procedure with the simulator fragments slightly distracted by 2.0 - 3.0 mm but otherwise properly aligned to simulate a fracture with restored angulation, and rotation.

2. Wear proper eye protection and gloves.

3. Loosen the right vise clamp securing the distal fragment to simulate a displaced fracture.

4. Normally, an average of 3L of irrigation solution (distilled water or isotonic saline) is used for each successive Gustilo Type (i.e., 6L for Gustilo Type II and 9L for Gustilo Type III) for wound lavage of an open tibial fracture to reduce the risk of infection.[1][2][3] However, an empty syringe can be used to simulate wound lavage during this simulation training.

5. Normally, all foreign material and non-viable tissue is debrided to reduce the risk of infection and minimize wound complications.[3][4][30] However, the simulator does not display foreign material or non-viable tissue so this step is skipped during this simulation training.
2
Reduce and Stabilize Fracture

1. Normally, the wound is extended if necessary to directly visualize and access the fracture. However, the simulator does not have simulated soft tissue so this step is skipped during this simulation training.

2. Normally, manual longitudinal traction can be applied to the distal lower extremity to reduce the fracture while directly visualizing the fracture. However, the simulator does not have a simulated distal lower extremity so this step is skipped during this simulation training.

3. Use bone reduction forceps to manually reduce the fracture and restore alignment

  • Bone apposition > 50%
  • Angulation < 10 degrees in any plane
  • Rotation < 10 degrees
  • Length discrepancy < 2 cm shortening
  • No distraction (lengthening)*

Normally, restoration of rotational alignment is confirmed by visually checking the position of the big toe and the alignment of the middle of the second toe with the center of patella.[10] However, the simulator does not include a foot or patella so the tibial crest will be visually inspected and palpated to verify restoration of rotational alignment during this simulation training.

At 0 degrees of rotation, the big toe is pointing straight up towards the ceiling and the middle of the second toe is aligned with the center of the patella. If the distal lower extremity is rotated > 10 degrees, it should be described as externally or internally rotated. External rotation is when the foot is turned outward (outtoeing) and internal rotation is when the foot is turned inwards (intoeing).

Normally, the medial malleolus of both limbs is palpated under sterile conditions to estimate and compare the length of the reduced limb to the uninjured limb. Then a measuring tape is used to measure and compare the limb length (from the anterior superior iliac spine to the medial malleolus) of both legs to confirm acceptable length discrepancy in the injured leg after dressings have been applied.[11] However, the simulator does not display the contralateral limb, anterior superior iliac spine or medial malleolus so the fracture line will be visually inspected for shortening or distraction to confirm that the fracture has been adequately reduced during this simulation training.

4. If required, adjust the fragments to achieve an adequate reduction

  • Bone apposition > 50%
  • Angulation < 10 degrees in any plane
  • Rotation < 10 degrees
  • Length discrepancy < 2 cm shortening
  • No distraction (lengthening)*

5. Apply and tighten bone holding forceps to maintain reduction.

6. Tighten right vise clamp and remove bone reduction forceps once fracture is stabilized.
3
Place Far Schanz Screws In Each Fragment

1. Position the “far” Schanz screw (furthest from the fracture line) in the proximal fragment medial or distal to the tibial tuberosity while avoiding traumatized soft tissues.* Inserting the Schanz screw medial or distal to the tibial tuberosity avoids tethering of the patellar ligament and penetration into the knee joint.[12]

2. Normally, the "far" Schanz screw in the distal fragment should be placed at least two fingers’ breadth proximal to the medial malleolus while avoiding traumatized soft tissues to avoid entry into the ankle joint.* However, the simulator does not display the medial malleolus for this simulation training.

3. Position the “far” Schanz screws as widely spaced as possible into each fragment while avoiding traumatized soft tissues, and entry into knee and ankle joints.* The wide placement of near and far Schanz screws in each fragment permits better control of displacing forces and optimizes stabilization of the reduction.[13][14][15][16]

4. Use a 22 blade scalpel to make a stab incision in the soft tissue overlying the anteromedial tibial wall for each Schanz screw.[17] However, the simulator does not have simulated soft tissue for this simulation training.

5. Use dissecting scissors to spread the simulated soft tissue apart in each stab incision to expose the bone for drilling. However, the simulator does not have simulated soft tissue for this simulation training.
4
Insert Far Schanz Screws Into Safe Zones of the Tibia

1. Insert a 5.0 mm diameter self-drilling Schanz screw into the powered surgical drill.

2. Insert the chuck key into the opening in the drill (watch video from 1:11 to 1:15). Turn the chuck key clockwise to tighten the drill over the Schanz screw.

3. Engage the switch for forward drilling direction on the drill. NOTE: Different drills have different locations for the switch that controls forward drilling direction.

4. Press the on/off trigger to confirm that the drill is ready for use. The Schanz screw tip should be rotating in a clockwise direction when the drill is pointing forward.

5. Slide the 5.0 mm drill sleeve over the 5.0 mm diameter Schanz screw. If using 4.5 mm diameter self-drilling Schanz screws for this simulation training, this requires using a 4.5 mm drill sleeve instead of a 5.0 mm drill sleeve.

6. Normally, the drill sleeve is positioned directly on the cortex in each stab incision to protect the surrounding soft tissues when drilling.[17] However, the drill sleeve should be pulled back at least 3.0 mm above the near cortex once drilling has commenced during this simulation training to prevent plastic strands from getting stuck inside the drill sleeve.

7. Place each "far" Schanz screw tip directly on the near cortex of the anteromedial tibial wall. Inserting Schanz screws into the thick anterior tibial crest is not recommended because the screw tip can slip medially or laterally and injure soft tissue.[22]

8. Insert both "far" Schanz screws in the proximal and distal fragments at an identical drill trajectory angle between 30°-60° relative to the tibial crest to reduce the risk of damage to neurovascular structures.*[18][19]
5
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Oscillogram of Bicortical Drilling of Tibial Fracture
Power Drill Far Schanz Screws Into Near Cortex

1. Normally, irrigation should be provided when drilling is performed to reduce the risk of thermal osteonecrosis.[20] However, an assistant can simulate irrigation with an empty syringe while drilling is performed during this simulation training.

2. Place the "far" Schanz screw tip on the anteromedial tibial wall, start drilling with the screw tip rotating in a clockwise direction, and ensure that the tip does not slip on the near cortex.*

3. Power drill each Schanz screw through the near cortex of the anteromedial tibial wall. Pay attention to the sound changes and tactile feel as the Schanz screw penetrates the near cortex.* The drilling sound will decrease in volume and a loss of resistance ("give") can be felt when the screw tip passes through the near cortex into the cancellous bone.

4. Stop power drilling after passing through the near cortex and before or when the inner surface of the far cortex is reached, which can be easily felt by a sudden resistance to the screw tip.* This prevents plunging through the far cortex and damaging underlying soft tissue.

5. Insert the chuck key into the opening in the drill (watch video from 1:23 to 1:27), turn the chuck key anticlockwise, and detach the drill from the Schanz screw.

6. Remove the drill sleeve from the "far" Schanz screw.
6
Manually Advance Schanz Screws Into Far Cortex
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The protruding tip of the self-drilling Schanz screw can injure the underlying soft tissue.[31] Manual advancement of the Schanz screw reduces the risk of a Schanz screw perforating the far cortex and plunging into the soft tissue.

1. Slide the universal chuck with T-handle over the Schanz screw.

2. To tighten the chuck over each Schanz screw, (i) manually rotate the proximal part of the chuck clockwise (click here to watch 20 second video) or (ii) insert the chuck key into the opening in the chuck and turn the chuck key clockwise (click here to watch 19 second video).

3. Use the T-handle to turn each Schanz screw clockwise for one to two 360 degree rotations to anchor the screw tip into the far cortex without exiting the far cortex.*[31] Resistance can be felt when the Schanz screw is being anchored into the inner side of the far cortex.

4. When manually advancing each Schanz screw into the far cortex, a loss of resistance ("give") should not be felt because this signifies that the Schanz screw has perforated the far cortex.

5. To detach the chuck from each Schanz screw, (i) manually rotate the proximal part of the chuck anticlockwise (click here to watch 23 second video), or (ii) insert the chuck key into the small, circular opening in the chuck and turn the chuck key anticlockwise (click here to watch 13 second video).

7
Use Pin-To-Rod Clamps to Fix Uniplanar Rod

1. Insert 4 pin-to-rod clamps on a 300 mm uniplanar rod.

2. Apply the two outer pin-to-rod clamps to connect the two "far" Schanz screws in each fragment to the 300 mm rod.[17]

3. Tighten the two outer pin-to-rod clamps initially by hand.

4. Leave the two inner pin-to-rod clamps loosened.

8
Place Near Schanz Screws In Each Fragment

1. Place the two “near” Schanz screws (closest to the fracture line) at least 2.0 cm (a finger breadth) from the fracture line while avoiding traumatized soft tissues.*[22][13] This helps prevent the placement of the Schanz screw within the fracture hematoma and risk having a pin site infection spread within the fracture.

2. Position the “near and far” Schanz screws as widely spaced as possible into each fragment while avoiding traumatized soft tissues.* The wide placement of near and far Schanz screws in each fragment permits better control of displacing forces and optimizes stabilization of the reduction.[13][14][15][16]

3. Use a 22 blade scalpel to make a stab incision in the soft tissue overlying the anteromedial tibial wall for each Schanz screw.[17] However, the simulator does not have simulated soft tissue for this simulation training.

4. Use dissecting scissors to spread the simulated soft tissue apart in each stab incision to expose the bone for drilling. However, the simulator does not have simulated soft tissue for this simulation training.
9
Insert Near Schanz Screws Into Safe Zones of the Tibia

1. Insert a 5.0 mm diameter self-drilling Schanz screw into the powered surgical drill.

2. Insert the chuck key into the opening in the drill (watch video from 1:11 to 1:15). Turn the chuck key clockwise to tighten the drill over the Schanz screw.

3. Engage the switch for forward drilling direction on the drill. NOTE: Different drills have different locations for the switch that controls forward drilling direction.

4. Press the on/off trigger to confirm that the drill is ready for use. The Schanz screw tip should be rotating in a clockwise direction when the drill is pointing forward.

5. Slide the "near" Schanz screw into the pin opening of a loosened pin-to-rod clamp attached to the 300 mm uniplanar rod.

6. Place each "near" Schanz screw tip directly on the near cortex of the anteromedial tibial wall. Inserting Schanz screws into the thick anterior tibial crest is not recommended because the screw tip can slip medially or laterally and injure soft tissue.[22]

7. Insert both "near" Schanz screws in the proximal and distal fragments at an identical drill trajectory angle to both "far" Schanz screws to reduce the risk of damage to neurovascular structures.*[18][19]
10
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Oscillogram of Bicortical Drilling of Tibial Fracture
Power Drill Near Schanz Screws Into Near Cortex

1. Normally, irrigation should be provided when drilling is performed to reduce the risk of thermal osteonecrosis.[20] However, an assistant can simulate irrigation with an empty syringe while drilling is performed during this simulation training.

2. Place the "near" Schanz screw tip on the anteromedial tibial wall, start drilling with the screw tip rotating in a clockwise direction, and ensure that the tip does not slip on the near cortex.*

3. Power drill each Schanz screw through the near cortex of the anteromedial tibial wall. Pay attention to the sound changes and tactile feel as the Schanz screw penetrates the near cortex.* The drilling sound will decrease in volume and a loss of resistance ("give") can be felt when the screw tip passes through the near cortex into the cancellous bone.

4. Stop power drilling after passing through the near cortex and before or when the inner surface of the far cortex is reached, which can be easily felt by a sudden resistance to the screw tip.* This prevents plunging through the far cortex and damaging underlying soft tissue.

5. Insert the chuck key into the opening in the drill (watch video from 1:23 to 1:27), turn the chuck key anticlockwise, and detach the drill from the Schanz screw.
11
Manually Advance Schanz Screws Into Far Cortex
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The protruding tip of the self-drilling Schanz screw can injure the underlying soft tissue.[31] Manual advancement of the Schanz screw reduces the risk of a Schanz screw perforating the far cortex and plunging into the soft tissue.

1. Slide the universal chuck with T-handle over the Schanz screw.

2. To tighten the chuck over each Schanz screw, (i) manually rotate the proximal part of the chuck clockwise (click here to watch 20 second video) or (ii) insert the chuck key into the opening in the chuck and turn the chuck key clockwise (click here to watch 19 second video).

3. Use the T-handle to turn each Schanz screw clockwise for one to two 360 degree rotations to anchor the screw tip into the far cortex without exiting the far cortex.*[31] Resistance can be felt when the Schanz screw is being anchored into the inner side of the far cortex.

4. When manually advancing each Schanz screw into the far cortex, a loss of resistance ("give") should not be felt because this signifies that the Schanz screw has perforated the far cortex.

5. To detach the chuck from each Schanz screw, (i) manually rotate the proximal part of the chuck anticlockwise (click here to watch 23 second video), or (ii) insert the chuck key into the small, circular opening in the chuck and turn the chuck key anticlockwise (click here to watch 13 second video).

12
Stabilize and Inspect Reduction

1. Use the 11 mm spanner with T-handle wrench for final tightening of the four pin-to-rod clamps around the 300 mm rod.*

2. Verify the reduction visually, and with gentle palpation of the tibial crest at the fracture line to confirm whether the alignment is within acceptable parameters

  • Bone apposition > 50%
  • Rotation < 10 degrees

Normally, restoration of rotational alignment is confirmed by visually checking the position of the big toe and the alignment of the middle of the second toe with the center of patella.[10] However, the simulator does not include a foot or patella so the tibial crest will be visually inspected and palpated to verify restoration of rotational alignment during this simulation training.

At 0 degrees of rotation, the big toe is pointing straight up towards the ceiling and the middle of the second toe is aligned with the center of the patella. If the distal lower extremity is rotated > 10 degrees, it should be described as externally or internally rotated. External rotation is when the foot is turned outward (outtoeing) and internal rotation is when the foot is turned inwards (intoeing).

3. Visually inspect the fracture line to confirm that the reduction is adequate

  • Length discrepancy < 2 cm shortening
  • No distraction (lengthening)

Normally, the medial malleolus of both limbs is palpated under sterile conditions to estimate and compare the length of the reduced limb to the uninjured limb. Then a measuring tape is used to measure and compare the limb length (from the anterior superior iliac spine to the medial malleolus) of both legs to confirm acceptable length discrepancy in the injured leg after dressings have been applied.[11] However, the simulator does not display the contralateral limb, anterior superior iliac spine or medial malleolus so the fracture line will be visually inspected for shortening or distraction to confirm that the fracture has been adequately reduced during this simulation training.

4. Normally, the bone holding forceps are removed once fracture is stabilized with external fixator frame and acceptable alignment is confirmed.

5. Normally, the pin sites are inspected for skin tenting. If skin tenting is present, the stab incision should be widened to release any soft tissue tension around the pin site to reduce the risk of inflammation and pin infection.[23] However, the simulator does not have simulated soft tissue so this step is skipped during this simulation training.
13
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Normally, a measuring tape should be used to measure and compare the limb length (from the anterior superior iliac spine to the medial malleolus) of both legs to confirm acceptable length discrepancy in the injured leg after dressings have been applied.[11]
Apply Dressing and Evaluate Extremity

1. Normally, the extremity should be cleaned and sterile gauze dressings applied to all 4 pin sites at the end of the procedure. However, this step is skipped during this simulation training.

2. Normally, a measuring tape should be used to measure and compare the limb length (from the anterior superior iliac spine to the medial malleolus) of both legs to confirm acceptable length discrepancy in the injured leg after dressings have been applied.[11] However, the simulator does not display the contralateral limb or anterior superior iliac spine so this step is skipped during this simulation training.

3. Normally, the Gustilo open-fracture classification for the injury should be re-evaluated after debridement in the operating room, and the antibiotic regimen and surgical treatment plan updated accordingly.[24][25][26][27] If the injury is re-classified to a Gustilo Type IIIB or Type IIIC, then referral to a tertiary center with specialist care is warranted. A Gustilo Type IIIC injury is a surgical emergency. However, the simulator does not have simulated soft tissue so this step is skipped during this simulation training.

Gustilo Open-Fracture Classification

Gustilo Open-Fracture Classification[25][26]
Gustilo Type I: An open fracture with a wound less than 1 cm long and clean.
Gustilo Type II: An open fracture with a laceration more than 1 cm long without extensive soft tissue damage, flaps, or avulsions.
Gustilo Type IIIA: Adequate soft-tissue coverage of a fractured bone despite extensive soft-tissue laceration or flaps, or high-energy trauma irrespective of the size of the wound.
Gustilo Type IIIB: Extensive soft-tissue injury loss with periosteal stripping and bone exposure. This is usually associated with massive contamination.
Gustilo Type IIIC: Open fracture associated with arterial injury requiring repair.
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If the injury is re-classified to a Gustilo Type IIIB or Type IIIC, the patient should be referred to a tertiary center with specialist care. A Gustilo Type IIIC injury is a surgical emergency.

Self-Assessment Framework

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Self-assessment

After the reduced fracture has been stabilized with the modular external fixator, please go to this link to follow the instructions on how to use a cellphone to take 5 post-operative photos ("digital X-rays"), and complete the printed Training Logbook

Training Module Certificate of Completion

Once the self-assessment framework has been completed:

  1. Go to this link.
  2. Click on "Get your certificate" button under the "Menu" section in the upper right corner of the module page.
  3. Type in your name, download and print out a certificate of completion for this training module.
  4. Photograph your certificate on your cellphone as a backup and file the printed certificate in your training records.

Acknowledgements

This work is funded by a grant from the Intuitive Foundation. Any research, findings, conclusions, or recommendations expressed in this work are those of the author(s), and not of the Intuitive Foundation.

References

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