synonyms: tibial shaft fracture intramedullary nail
Proximal 1/3 Tibial Shaft Fracture IM Nail Indications
- high-energy fx
- modereate to severe soft-tissue injury
- unstable fracture pattern->5coronal angulation, >10sagittal angulation, >5rotation, >1cm shorteing
- open fx
- compartment syndrome
- ipsilateral femur fx
- inability to maintain reduction
- intact fibula
Proximal 1/3 Tibial Shaft Fracture IM Nail Contraindications
- Severely contaminated open tibial shaft fracture
- External fixator with pin site infection
- External fixator in place >2 weeks (relative)
- Articular comminution: Consider ORIF vs Ilizarov.
Proximal 1/3 Tibial Shaft Fracture IM Nail Alternatives
- External Fixation
- Casting / Functional Brace
- Ring / Ilazarov fixator
Proximal 1/3 Tibial Shaft Fracture IM Nail Pre-op Planning
- Proximal fractures have strong tendency towards anterior displacement (procurvatum) of proximal fragment and valgus alignment due to: metaphyseal bony anatomy, eccentric starting point, patellar tendon forces, Herzog curve of the nail.
- Consider lateral starting point, provisional anteromedial unicortical plating, blocking screws, external fixation, percutaneous clamps. Reduction must be maintained during reaming, implant placement and interlocking.
- Ideal starting point: medial border of the lateral tibial eminence on a true AP view and very proximal and anterior on a true lateral view. Starting point is proximal and lateral.
- Reamed nails for closed fxs have slightly higher healing rate and less hardware failure(locking bolts) than unreamed nails. NO difference in malunion, infection, compartment syndrome, or knee pain.
- Discuss postoperative knee pian the patients pre-operatively.
- See Open Fracture.
- Case Card.
Proximal 1/3 Tibial Shaft Fracture IM Nail Technique
- Sign operative site.
- Pre-operative antibiotics, +/- regional block.
- General endotracheal anesthesia
- Supine position on radiolucent fracture table. All bony prominences well padded.
- Ensure adequate C-arm images can be taken in A/P and lateral planes.
- Prep and drape in standard sterile fashion.
- Consider placing 2-pin traveling traction external fixator to reduce fracture and maintain reduction.
- Varify reduction. Rotation can be assess by ensuring that the second toe aligns with the tibial tuberosity.
- Longitundinal 2-3cm incision
- Dissection medial to patellar tendon.
- Nail entry site is proximal and lateral. Entry site is proximal(just distal to articular surface) and lateral generally in line with the lateral intercondylar eminence.
- Make starting point with awl. Sagittal plane entry point parallel to the anterior cortex of the proximal fragment
- Place ball-tiped guidewire across fracture site.
- Ream in 0.5cm increments to 1.5mm greater than selected nail size.
- Measure nail length off guidewire.
- Blocking Screws: Consider for fractures with short proximal or distal fragments. Screw is placed in the short fragment, close to the fracture, on the concave side of the axial deformity.(Stedtfeld H JBJS 2004;86A supplement 2,:17)
- Place selected nail.
- Remove guide wire
- Place distal locking screws using freehand technique.
- Back slap the nail to compress the fracture site and eliminate any distraction which occured during nail placement.
- Place proximal locking screws using targeting jig. Consider proximal interlocking with knee in extension.
- Remove jig
- Evaluate nail placement proximally, distally and at fracture site using c-arm.
- Close in layers.
Proximal 1/3 Tibial Shaft Fracture IM Nail Complications
- Knee pain
- Painful hardware
- Compartment Syndrome
- DVT / PE
Tibial Shaft Fracture IM Nail Follow-up care
- Post-op: Apply bulky Jones dressing with posterior mold to avoid equinus contracture. Elevate. Consider DVT prophyaxis.
- 7-10 Days: Remove splint, wound check. WBAT, PT, knee, ankle mobilization based on fracture stability / soft tissues.
- 6 Weeks: Xrays. Advance PT
- 3 Months: Xrays. Consider bone stimulator/nail dynamization if union is not evident. Sport specific PT.
- 6 Months: Return to full activities
- 1Yr: follow-up xrays, asssess outcomes.
Tibial Shaft Fracture IM Nail Outcomes
Tibial Shaft Fracture IM Nail Review References
- Ricci WM, O'Boyle M, Borrelli J, Bellabarba C, Sanders R. Fractures of the proximal third of the tibial shaft treated with intramedullary nails and blocking screws. J Orthop Trauma. 2001 May;15(4):264-70.
- Krettek C, Miclau T, Schandelmaier P, Stephan C, Mohlmann U, Tscherne H. The mechanical effect of blocking screws ("Poller screws") in stabilizing tibia fractures with short proximal or distal fragments after insertion of small-diameter intramedullary nails. J Orthop Trauma. 1999;13(8):550-3
- (Buehler, JOT 11:218, 1997)
- Rockwood and Greens
- Master Techniques in Orthopaedic Surgery: Fractures
- Lang GJ, Cohen BE, Bosse MJ, Kellam JF. Proximal third tibial shaft fractures. Should they be nailed? Clin Orthop Relat Res. 1995 Jun;(315):64-74