Materials and Equipment

This module allows medical officers and surgeons who are not orthopedic specialists to become confident and competent in irrigation and debridement, powered and manual drilling, positioning and correctly inserting Schanz screws, and constructing the uniplanar external fixator frame 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.

Patient Positioning, Prepping, and Draping

This simulation-based skills training requires 5 people (1 simulated patient, 1 surgical practitioner, 2 assistants, and 1 person to observe and complete the Training Logbook Checklist). The team roles can be rotated to give each learner the opportunity to practice the surgical practitioner role.

Table 1. Materials and Equipment for Patient Positioning, Prepping, and Draping

#	Item	Quantity	Reference Image	Reusable for Simulation-Based Skills Training
1.A	Cellphone to access the online Training Logbook or 1B.1 and 1B.2	1		Not applicable
1B.1	Paper-based Training Logbook (if unable to access online Training Logbook)	1		No
1B.2	Clipboard, and pen (if using paper-based Training Logbook)	1		Yes
3	Operating room or medical examination table or any table long and strong enough to support a simulated patient in a supine position	1		Yes
4	Sponge stick	1		Yes
5	Gauze pad	1		Yes
6	Surgical drapes	3		Yes, if using cloth surgical drapes
7	Towel clamps	3		Yes
8	Surgical towel	1		Yes
9	Gauze roll	1		Yes

Uniplanar External Fixation for an Open Tibial Shaft Transverse Fracture

For this simulation-based skills training, a pair of learners is assigned to a station. While one learner conducts the simulation-based skills training, the other learner observes and completes the Training Logbook Checklist. The learner roles are then switched.

Table 2. Materials and Equipment for Uniplanar External Fixation for an Open Tibial Shaft Transverse Fracture

#	Item	Quantity	Reference Image	Function	Reusable for Simulation-Based Skills Training	Comments
1	Cellphone	1 per learner		Used by learner to access the Training Logbook and to take the photos of the Tibial Shaft Transverse Fracture Simulator for the Self-Assessment Framework to document technical competence on the simulator	Not applicable	Supplied by each learner
2	Training Logbook	1 per learner		Used by learner to document technical competence on the simulator	No	Can be accessed on a mobile device or downloaded and printed locally
3	Clipboard	1 per station		Used by learner to fill out a paper- based Training Logbook to document technical competence on the simulator	Yes	Locally available
4	Pen	1 per station		Used by learner to fill out a paper- based Training Logbook to document technical competence on the simulator	Yes	Locally available
5	Eye protection	1 per learner for 2 learners training at a station		Used to protect the eyes of both learners at each station during the simulation-based skills training	Yes	Locally available
6	Gloves	2 pairs for 2 learners training at a station		Worn by both learners at each station during the simulation-based skills training	No	Locally available
7	3D Printed Adult Male Tibial Bone Model #1	2 per learner		This open-source, 3D printed bone model can be locally reproduced on affordable, desktop 3D printers available worldwide and has excellent visual, tactile, and acoustic fidelity to allow learners (who have no prior experience with drilling into bone) teach themselves the skills to prevent plunging through the far cortex.	To experience the proper tactile feel when drilling into bicortical bone, every learner should perform at least one simulation-based skills training procedure with 4 new, unused Schanz Screws and a new, unused Tibial Shaft Transverse Fracture Simulator.	Click here to find local 3D print on demand services
8	3D Printed Adult Male Tibial Bone Model #2	2 per learner		This open-source, 3D printed bone model can be locally reproduced on affordable, desktop 3D printers available worldwide and has excellent visual, tactile, and acoustic fidelity to allow learners (who have no prior experience with drilling into bone) teach themselves the skills to prevent plunging through the far cortex.	To experience the proper tactile feel when drilling into bicortical bone, every learner should perform at least one simulation-based procedure with 4 new, unused Schanz Screws and a new, unused Tibial Shaft Transverse Fracture Simulator.	Click here to find local 3D print on demand services
9	Cellophane	1 roll per workshop		Wrapped around the slightly distracted 3D printed proximal and distal fracture fragments to simulate the soft tissue envelope and permit visual inspection for targeted self-assessment by the learner	No	Locally available
10A	Vise clamps; or 10B.1 to 10B.4	1 pair per station		Secures the Tibial Shaft Transverse Fracture Simulator for safe simulation-based skills training; positioned so the fracture ends are distracted by 2.0 - 3.0 mm but are otherwise properly aligned to simulate a fracture with restored angulation, and rotation; and to simulate a patient in the supine position	Yes	You could purchase these vise clamps on Amazon, Jumia or Taobao. If not locally available, use items 10B.1-10B.4
10B.1	Wood board	1 per pair of learners		Lower-cost alternative to vise clamps for securing the Tibial Shaft Transverse Fracture Simulator for safe simulation-based skills training	No	Locally available
10B.2	Drill bit	1-2 per workshop		Used for the lower-cost alternative to vise clamps to secure the Tibial Shaft Transverse Fracture Simulator for safe simulation-based skills training	No	Locally available
10B.3	Hammer	1 per workshop		Used for the lower-cost alternative to vise clamps to secure the Tibial Shaft Transverse Fracture Simulator for safe simulation-based skills training	Yes	Locally available
10B.4	Nails	4 per Tibial Shaft Fracture Simulator		Used for the lower-cost alternative to vise clamps to secure the Tibial Shaft Transverse Fracture Simulator for safe simulation-based training	No	Locally available
11	Syringe, 50 mL	1 per station		Used for irrigation of open wounds	Yes	Locally available
12	Bone reduction forceps	1 per station		Used to manually reduce the fracture, compress the fragments together, and restore alignment	Yes	Can be loaned by a local facility that performs orthopedic surgical procedures
13	Bone holding forceps, medium size	1 per station		Used to maintain reduction and is removed after the fracture is stabilized with the external fixator frame and acceptable alignment is confirmed	Yes	Can be loaned by a local facility that performs orthopedic surgical procedures
14	Scalpel blade and handle	1 per station		Used to make a stab incision in the soft tissue at the insertion site for each Schanz screw; and to extend the wound to adequately expose the open fracture for direct visualization of the fracture (if required)	Yes	Can be loaned by a local facility that performs orthopedic surgical procedures
15	Sharps container	1 per workshop		Used to store the scalpel blades for safe simulation-based skills training	Yes	Locally obtained.
16	Dissecting scissors	1 per station		Used to dissect through the soft tissue to expose the bone at the insertion site for each Schanz screw	Yes	Can be loaned by a local facility that performs orthopedic surgical procedures
17	Any powered surgical drill that is compatible with 4.5 or 5.0 mm diameter self-drilling Schanz screws	1 per station		Drives Schanz screw through the near cortex of the fracture fragment, also referred to as a "power drive"	Yes	Can be loaned by a local facility that performs orthopedic surgical procedures.
18	Chuck key for surgical drill	1 per station		Inserted into the circular opening in the drill chuck body and used to tighten or loosen the 3-jaw chuck over the Schanz screw	Yes	Can be loaned by a local facility that performs orthopedic surgical procedures
19	Self-drilling Schanz screws, 5.0 mm x 200 mm x 30 mm	4 per learner		Inserted into fracture fragments, also referred to as "pins" or "half-pins"	To experience the proper tactile feel when drilling into bicortical bone, every learner should perform at least one simulation-based procedure with 4 new, unused Schanz screws and a new, unused Tibial Shaft Transverse Fracture Simulator. Schanz screws could potentially be re-used by a learner up to 3 times but re-using Schanz screws may cause mechanical failure of a new or used 3D Printed Tibial Shaft Transverse Fracture Simulator.	Ask your local orthopedic surgeon to obtain through their local orthopedic surgical hardware supplier
20	Drill sleeve for 4.5 mm or 5.0 mm Schanz screws	1 per station		Used to protect the soft tissue when drilling the 2 "far" pins	Yes	Can be loaned by a local facility that performs orthopedic surgical procedures
21	Universal chuck with T-handle	1 per station		Allows for manual advancement of the Schanz screw into the far cortex without exiting the far cortex	Yes	Can be loaned by a local facility that performs orthopedic surgical procedures
22	Chuck key for universal chuck with T-handle	1 per station		Inserted into the circular opening in the chuck body and used to tighten or loosen the 3 jaws of the universal chuck with T-handle over the Schanz screw	Yes	Can be loaned by a local facility that performs orthopedic surgical procedures
23	Universal pin-to-rod clamp (single pin)	4 per station		Combines a pin to the uniplanar rod	Yes	Can be loaned by a local facility that performs orthopedic surgical procedures
24	Uniplanar rod, 11 mm diameter x 300 mm length	1 per station		Links pins with clamps; a metal rod is cheaper but a carbon fiber rod is radiolucent which permits better visualization of the fracture on X-ray	Yes	Can be loaned by a local facility that performs orthopedic surgical procedures
25	11 mm spanner with T-handle	1 per station		Assists in final tightening of the 4 pin-to-rod clamps	Yes	Can be loaned by a local facility that performs orthopedic surgical procedures
26	Ruler	1 per station		Used by learner to objectively confirm proper fracture alignment of the Tibial Shaft Transverse Fracture Simulator for the Training Logbook Checklist	Yes	Locally available
27	Protractor	1 per station		Used by learner to measure the drill trajectory angles of the Schanz Screws for the Training Logbook Checklist	Yes	Locally available

Hardware Suppliers

Any locally available 4.5 or 5.0 mm diameter self-drilling Schanz Screws and compatible uniplanar external fixator hardware, instruments, and powered surgical drill can be used for this simulation-based skills training module.

We recommend obtaining hardware from your local orthopedic surgical hardware supplier. We have included a list of potential surgical hardware suppliers who may ship to your location below:

1. Emmanuel Madhu, Managing Director, Ortho Support Limited, University of Abuja Teaching Hospital, Abuja Office, PMB 228, Abuja Gwagwalada, 902101, Nigeria, email: ololonwabig2@gmail.com, phone: +234 809 369 4250
2. Apothecaries Sundries Mfg. Pvt. Ltd. (ASCO), ASCO House, 229 Udyog Vihar Phase IV, Gurugram-122015, Haryana, India, email: info@ascomedical.com, phone: +91 935 099 2022
3. Uma Surgicals, 102/103, Auto Commerce House, Kennedy Bridge, Nana Chowk, Mumbai - 400 007, India, email: info@umasurgicals.com, phone: +91-22-23877076 / +91-022-23856015 / +91-022-23855627
4. Surgivalley, 143-C Small Industrial State Shahabpura Sialkot, 51310, Pakistan, email: info@surgivalley.com, phone: +923222800090
5. Orthopedics International, Unit 3, Firs Farm, Stagsden, Bedfordshire, MK43 8TW, United Kingdom, email: tim@medaid.co.uk, phone: +44(0)1234 930394
6. Stryker, 1941 Stryker Way, Portage, MI 49002, USA, phone: +1 269 385 2600; fax: +1 269 385 1062

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.