Knee: For distal femur and/or proximal tibia fractures including those involving the articular surfaces, a knee spanning fixator is most appropriate. Two pins each in the intact femur and tibia can be connected by bars. To maximize stability of this longer construct, good pin spread and/or multiple bars should be considered. As with other long bone fractures, longitudinal traction is used to correct coronal and sagittal alignment. The fixator should be locked with the knee in flexion. A posterior slab, short leg splint can be helpful to control ankle plantarflexion and provide additional soft tissue rest and pain control as the gastrocnemius muscle crosses the knee joint.

Tibia: The neurovascular bundle runs along the bone’s posterolateral surface. This leaves the anteromedial surface free for safe pin placement. The thin layer of subcutaneous tissue overlying the bone makes this surface easily palpable along its entire length. The direct anterior tibial crest should be avoided as it is significantly thicker than the rest of the bone, and pin placement is difficult even with a power drill. Pins should be placed about 1 cm medial to the anterior crest to avoid the crest as excessive drilling can result in thermal necrosis, pin loosening and eventual infection.