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胫骨远端骨折关节桥接式外固定架 阶段1)-闭合复位和关节桥接外部固定，可能的腓骨内固定术 With an external fixator, the joint can be reduced and stabilized temporarily in an adequate position while awaiting decrease of the swelling and soft-tissue healing. Fixation of an associated fibular fracture adds stability and contributes to overall reconstruction. However, the possibility of an unsatisfactory reduction and additional soft-tissue injury must be considered before undertaking this step. 用外固定架固定，当在等待肿胀消退和软组织愈合的过程中，关节可以在一个适当的位置得到复位和暂时稳定。腓骨骨折内固定可增加踝关节稳定性并有助于最后重建，然而，在进行这一步之前，必须考虑腓骨不能达到令人满意复位或存在增加软组织损伤可能性。
It is sufficient to use just a simple external fixator as a bridging fixator. However, if it is anticipated the frame may be on for a prolonged period of time, a more sophisticated frame construct is usually necessary. 用一个简单的外固定架作为桥接外固定器就足够了。然而，如果外固定架被预期可能用较长的一段时间，则应该选择一个稳固的框架构建。
1.3 腓骨情况（完整） If the fibula is stabilized or intact, a medial frame with a medial half-pin into the calcaneal tuberosity is usually sufficient for maintenance of length. Midfoot or forefoot extension of the external fixator should be considered to maintain the foot in a neutral position. 如果腓骨稳定或完整，一个固定在跟骨结节内侧的半针外架（即不穿出对侧）通常情况下就足以用来维护长度。中足或前足延长外固定器可以保证维持足部在一个中立的位置。
1.4 腓骨情况（粉碎） If the fibula is fractured and remains initially unfixed because of soft-tissue concerns, or because the fibular fracture pattern is too complex, a centrally threaded transfixion pin should be placed through the calcaneal tuberosity. Midfoot or forefoot extension of the external fixator should be considered to maintain the foot in a neutral position. 如果腓骨骨折因为软组织原因或因粉碎严重而没有进行固定，可以用一个带螺纹固定针贯穿跟骨结节进行固定。中足或前足延长外固定器可以保证维持足部在一个中立的位置。
2、固定针置入 2.1 Insertion technique 插入技术 Safe zone 安全区域 In order to avoid tendon penetration or injuries to nerves, vessels, and muscles, the surgeon must be familiar with the anatomy of the different cross-sections of the lower leg and make use of the recommended pin placement sites . 为了避免穿透肌腱或神经血管肌肉，手术医生必须熟悉小腿不同截面解剖并使用推荐固定针插入位。
Skin incision 皮肤切口 The skin incision should be long enough to avoid tension. It should be placed medially on the subcutaneous bone border. At the end of the operation, the skin incisions should be inspected. Enlargement of the incision should be undertaken in case of tension. 皮肤切口应该足够长以避免张力，它应该放置胫骨干内侧皮下。手术结束的时候,皮肤切口应进行检查。如果需要可以扩大切口防止皮肤紧张。
Predrilling 钻孔前准备 It is advisable to predrill the tibial diaphysis in order to avoid heat damage to the bone and to ensure that both cortices are engaged correctly. Use an appropriate sleeve when predrilling to protect soft tissues. 应在胫骨干钻孔以避免热骨损伤，同时要确保穿入两侧皮质，使用适当的套筒以保护软组织。
2.2 Insertion of Schanz screws 插入斯氏针 Insert Schanz screw into each main fragment using a trocar sleeve protector. Ensure that the opposite cortex is engaged. Correct depth insertion may be achieved by feeling the opposite cortex. Note that intraoperative x-rays can be deceptive. If the control x-ray shows an empty hole in the opposite cortex, the screw has not been inserted far enough. 在套筒的保护下在每一个主要骨折端打入斯氏针，并确保穿入对侧皮质。达到正确的深度时对侧皮质有抵抗感。注意术中x射线可能具有欺骗性。如果X片显示对侧皮层有一个空洞影，则表示螺丝没有插入足够的深度。
2.2 Insertion of Schanz screws 插入斯氏针（自钻型） Self-drilling Schanz screws may be used. However, the thick tibial cortex should be predrilled first. These pins are inserted through the near cortex until they just penetrate into the far cortex, but do not pass through it. Self-drilling screws may be inserted into cancellous bone without predrilling. 可以使用自钻斯氏针，然而，胫骨皮质较厚的地方应该预先钻孔。这些斯氏针（自钻）拧入到仅仅穿入但未穿出对侧皮质。自钻斯氏针可以拧入跟骨不用预先钻孔。
3、构建框架 3.1 Preliminary remark 预先标记 Various external fixation frames can be used to stabilizethe distal tibia region. We illustrate a simple configuration. As explained above in step 1, the surgeon may need to select another alternative. Usually used for temporary stabilization, a joint-bridging frame can be part of definitive treatment if necessary. 多种外固定架可以用来稳定胫骨远端区域。我们演示一个简单的构造过程。正如前面解释的(在步骤1，手术医生可能需要选择另外一种方法了。通常用于临时稳定，一个关节桥接外固定架可以作为部分最终治疗方案。
3.2 Tibio-calcaneal bar 胫骨--跟骨连接杆 Insert two Schanz screws in the sagittal plane and slightly medial to the anterior tibial crest at an adequate distance above the fracture. 在胫骨骨折线上面较远水平，从矢状面胫骨嵴的稍内侧打入两枚平行斯氏针。 Then insert a third Schanz screw from medial to lateral into the calcaneal tuberosity. Take care to avoid damage to the posterior tibial neurovascular bundle. Connect the proximal Schanz screw and the calcaneal screw with a tube / bar. 然后，再从跟骨结节从内到外插入第3枚斯氏针（视腓骨情况决定穿出或不穿出跟骨），注意不要损伤胫后神经血管束，用一个连接杆连接胫骨近端的斯氏针和跟骨的斯氏针
3.3 Tibiotarsal fixation 胫骨--跗骨固定 Extending the external fixator into the foot stabilizes soft tissues and avoids equinus and varus deformities. It is usually advisable for injuries in this region. Insert a small Schanz screw in the base of the second metatarsal and connect it to the distal Schanz screw in the tibia shaft, with the foot in a neutral position (tibiotarsal transfixation). 向前延伸固定到足部可以起到稳定软组织和避免马蹄足和内翻足畸形愈合的形成。这通常是个可取的伤害。插入一个小的斯氏针螺杆在第二跖骨的基底部连接到远端胫骨斯氏针螺丝上，固定使足保持在一个中立的位置。
3.4 Note 注意事项 Remember that the dorsalis pedis artery and veins and deep peroneal nerve lie on the medial side of the second metatarsal base. A pin inserted here requires blunt dissection to the bone and careful retraction. 记住足背动静脉和腓深神经位于第二跖骨基底的内侧面，在插入斯氏针时，要求钝性分离到达骨质，仔细牵开组织。
3.4 Note 注意事项 Alternatively, pins can be inserted into the bases of the first and fourth metatarsals. This controls foot position better, and avoids neurovascular structures. 或者，斯氏针可以插入到第1和第4跖骨基底，这样控制足位置更好，并且可以避免损伤足背神经血管束。
4、复位 4.1 操作跟骨的Schanz来纵向复位 Reduce the fracture by applying longitudinal traction to the foot and by manipulating the calcaneal pin. After checking reduction with image intensification in both planes, the position is held by the surgeon while the assistant tightens the clamps of the tibio-calcaneal rod. 通过纵向牵引足部和跟骨的斯氏针来帮助复位，通过正侧位透视检查复位情况，复位满意后由手术医生保持位置并由助手拧紧胫骨--跟骨连接杆。
4.2 矫正足的位置 The equinus position of the foot is subsequently corrected and the foot is fixed in neutral position by tightening the clamps of the tibia-metatarsal connection. Take care to avoid supination of the foot. 靠拧紧胫--咐骨连接杆把足固定在中立位，避免足的内翻和旋后。
5.1、完成固定 It is important to connect the two rods with a third rod in order to increase the stability of the frame construction. This anterior rod is illustrated. 用第3个连接杆把前两个连接杆连接起来以增加稳定性，如上图。
5.1、完成固定 Finally, tighten the triangular frame construct. 最后，拧紧三角型框架螺钉。
6、Conversion to internal fixation 转换为内固定 6.1 If the soft tissues are healing satisfactorily 软组织损伤愈合满意If the soft tissues are healing satisfactorily, without sign of pin-track infection, the external fixation can be removed and replaced with internal fixation at the same procedure. Conversion may be done as early as 5 -10 days after trauma, but after severe injuries, soft-tissue recovery may take longer. 如果软组织情况愈合满意，没有针道感染迹象，外固定支架固定可拆除并同时更换为内固定。更换时间可在创伤后5-10天内，但严重损伤后，软组织恢复时间可能会更长。 No clinical or laboratory signs of active infection No sign of pin-track infection Good-quality soft-tissue coverage for safe approach to the distal tibia Avoid prolonged delay; internal fixation should be applied as soon as soft tissues have recovered 没有临床或实验室表明有活动性感染迹象 没有针道感染迹象 胫骨远端手术区软组织覆盖条件良好 避免长期延误，当软组织恢复后就应立即实施内固定 7 Pitfall: Schanz screw track infection 技巧：Schanz针道感染 If there is any concern about Schanz screw site contamination, the following steps need to be taken: Remove the external fixator Debride and overdrill pin sites as necessary Temporarily stabilize the ankle joint with a splint, cast, or exceptionally, a new external fixator Let the Schanz screw tracks heal Proceed with internal fixation如果发生Schanz 针道污染迹象，可以采取以下办法预防： 去除外固定架 清创并清除针道周围组织 用夹板、石膏，特殊情况下可以另一个外固定架，暂时稳定踝关节。 使Schanz 针道愈合 再进行内固定 |
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