Safe surgical technique: intramedullary nail fixation of tibial shaft fractures

Abstract

Statically locked, reamed intramedullary nailing remains the standard treatment for displaced tibial shaft fractures. Establishing an appropriate starting point is a crucial part of the surgical procedure. Recently, suprapatellar nailing in the semi-extended position has been suggested as a safe and effective surgical technique. Numerous reduction techiques are available to achieve an anatomic fracture alignment and the treating surgeon should be familiar with these maneuvers. Open reduction techniques should be considered if anatomic fracture alignment cannot be achieved by closed means. Favorable union rates above 90 % can be achieved by both reamed and unreamed intramedullary nailing. Despite favorable union rates, patients continue to have functional long-term impairments. In particular, anterior knee pain remains a common complaint following intramedullary tibial nailing. Malrotation remains a commonly reported complication after tibial nailing. The effect of postoperative tibial malalignment on the clinical and radiographic outcome requires further investigation.

Keywords: Fracture; Intramedullary; Knee pain; Nail; Tibia.

Fig. 1

Compartment pressure measurement of the right leg anterior muscle compartment with a pressure needle

Fig. 2

a-f Right distal third spiral tibia fracture (a) with normal appearing preoperative radiographs of the ankle (b). Intraoperative fluoroscopic pictures demonstrating a non-contiguous minimally displaced posterior malleolus fracture (c) requiring surgical fixation (d). Follow-up radiographs (e-f) show uneventful healing of both tibia and ankle injury

Fig. 3

a-f Left distal third spiral tibia fracture (a) with normal appearing radiographs of the ankle (b). Preoperative CT scan shows a non-contiguous minimally displaced posterior malleolus fracture (c-d). Follow-up radiographs (e-f) show uneventful healing of both tibia and ankle injury

Fig. 4

a-b Intraoperative picture (a) demonstrating the suprapatellar starting point through a longitudinal split of the quadriceps tendon and cannula insertion through the patellofemoral joint. Corresponding intraoperative fluoroscopic pictures with lateral view of the starting point (b)

Fig. 5

Intraoperative picture demonstrating the soft tissue injury to the infrapatellar area as an indication for suprapatellar nailing in the semiextended position

Fig. 6

a-d The F-tool (a) allowing for reduction of a medially translated tibia fracture (b-d)

Fig. 7

a-c A percutaneously placed periarticular clamp (a) allowing for reduction of a distal third spiral tibia fracture (b-c)

Fig. 8

a-b In same patient, a percutaneously placed pointed reduction clamp (a) resulted in significant soft tissue compromise (b) which required changing to a different clamp

Fig. 9

a-e Open tibia fracture with significant comminution and bone loss (a). A unicortical plate was applied through the traumatic wound to achieve fracture reduction (b). The plate was maintained throughout the reaming process and nail placement (c). Following successful nail stabilization, the plate was removed (d-e)

Fig. 10

a-b Blocking screw placed anterior to posterior on the lateral side to prevent valgus deformity (a). Blocking screw placed posteriorly from medial to lateral preventing apex anterior deformity (b)

Fig. 11

a-b Anteroposterior (a) and lateral (b) fluoroscopic pictures demonstrating center/center position of the ball-tipped guidewire

Fig. 12

a-d Placement of distal interlocking screws through fluoroscopic imaging (a-b) versus electromagnetic guidance system (c-d)

Fig. 13

a-d Segmental tibia fracture (a-b) treated with intramedullary nailing with two distal and three proximal interlocking screws. Follow-up radiographs (c-d) demonstrate uneventful healing