Tibial shaft fracture: Reduction and stabilisation for fixation using the STORM device
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Tibial fractures are very interesting with a wealth of discussion amongst the Orthopaedic community on the best method of treatment or fixation. There are no national guidelines that recommend one treatment modality over the other and this is perhaps where the art in medicine comes into play.
Certain fracture patterns lend themselves to one treatment modality more than others, yet in the hands of an experienced surgeon, most fracture patterns can be treated with any of the options available. Of course of paramount importance as Surgeons we have to consider the patient and their treatment goals. For example some patients would not be able to comply with non-weightbearing, or a circular frame requiring daily pin site care. Our role as Orthopaedic Trauma surgeons is to assess the patient’s needs, discuss the available options and then collaboratively agree on the treatment strategy for them.
The STaffordshire Orthopaedic Reduction Machine (STORM) has been designed to facilitate tibial fracture reduction by Professor Peter Thomas and Professor Peter Ogrodnik. Professor Thomas observed that when treating tibial fractures with an Orthofix fixator the principle was to start with a deformed bone and apply a monolateral fixator. The fracture was then reduced and if the start point was one of deformity you’d be left with a straight bone but a deformed fixator. This meant that the fixator was mechanically disadvantaged because its alignment was not parallel with the long axis of the bone. In cases that are then subsequently dynamised, if the fixator body is not parallel with the bone axis, this causes a shearing vector across the fracture site and can lead to a hypertrophic nonunion. Also if the fixator half pins have not been placed an equal distance from the fracture site, as the patient walks, the proximal and distal fracture fragments will have differential movement and this could again lead to a hypertrophic nonunion.
These observations from a high volume trauma unit led to the development of the Intelligent Orthopaedics Services (IOS) fixator. The IOS fixator is a monolateral and low profile fixator that is applied to a reduced tibial shaft fracture with 3x half pins proximally and 3x half pins distally, to the fracture. Patient’s can full weightbear through the affected limb and also wear normal trousers. The IOS fixators are designed for use with unstable tibial shaft fractures requiring surgical stabilisation, they are available in a short version (fractures < 44mm) and a long version (fractures > 44mm but < 84mm).
This technique won’t describe or demonstrate the IOS fixator but to be able to apply one, then the bone must be anatomically reduced. This is where the STORM device comes in.
The STORM device allows any tibial fracture to be reduced. It was originally designed to be used with midshaft fractures to enable application of an IOS fixator but it can also be used with pilon fractures, low distal third fractures, midshaft fractures, proximal tibial fractures, tibial plateau fractures and segmental injuries. It is not a definitive treatment but makes treatment and reduction of complex injuries much more controlled and converts complex injuries into simple aligned fracture fragments.
The STORM device is similar to a half frame construct but has more options, including the ability to apply both coronal and sagittal plane translation to the fracture. This is achieved by inserting a 2.0mm fine wire through the proximal tibia and a second wire through the calcaneum. The wires are connected to the external STORM frame and both traction and rotation can be adjusted. Often simply applying traction will correct the alignment. In cases with residual translation, then two additional translation arms can be connected to the STORM device, and attached to the proximal and distal fracture segments with a single 4.5mm unicortical screw in each translation arm. Adjustment of the translation arms in the coronal plane allows medial and lateral translation. Adjustment in the sagittal plane allows correction of apex anterior / posterior deformities. Using the C-arm the fracture can be indirectly anatomically reduced before definitive stabilisation is commenced.
The STORM device is designed, manufactured and distributed by Metaphysis LLP in the UK, EU and USA. http://intelligent-orthopaedics.com
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Author: Ross Fawdington FRCS
Institution: The Queen Elisabeth Hospital, Birmingham,UK.
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