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Duke Orthopaedics
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Wheeless' Textbook of Orthopaedics

Discussion of IM Nails for Tibial Fracture


- Discussion:
     - history: Intramedullary nailing in fracture treatment: History, science and Küntscher's revolutionary influence in Vienna, Austria
     - healing and prognosis of tibia fracture
 
- PreOp Planning:

     - Contra-indications:
             - open growth plates; (pediatric tibial frx);
             - fractures w/ 4 cm of the ankle joint;
             - previous application of external fixator (relative contraindication - controversial);
             - proximal fourth tibial fractures (relative contraindication - controversial)
     - Soft tissue injury:
             - Open tibial frx (Gustillo classification):
             - Reconstruction for leg defects:
     - Comminution: (see Winquist classification):


- Technique of IM Nailing:


- Outcomes for IM Nails vs Other Treatment Methods:
    - external fixation vs IM nailing for tibial frx
    - Klemm and Borner (1986);
          - 401 tibial fractures: 308 closed, 93 open grade I (delayed nailing)
          - 81% of frx were considered unstable to shortening or rotation;
          - 94% w/ good to excellent results, 2.2% deep infection
    - Puno, et. al. (1986)
          - 201 tibial fractures:  AO type reamed slotted tibial nail w/ closed technique versus closed
                  reduction w/ cast application;
          - IM nail: 98% union rate (no malunions), 3.3% infection rate;
          - cast immobilzation:
                  - 90.1% unions, 4.3% malunions, 1.4% infections;
                  - initially 13% of fractures lost the reduction and required operation; 
    - Bone and Johnson
          - 76 primary fractures and 36 2ndary fractures (exfix/closed failures)
          - using AO or Grosse-Kemph IM Nailing;
          - union rate: 97% for both groups;
          - time to union: primary group: av 17.8 weeks vs secondary group: av 21.6 weeks
          - infection: 9% - mostly pts rx'ed w/ open procedures or open frx;
    - Bone, et al (1997)
          - retrospective study of 99 patients w/ closed tibial shaft fractures treated either w/ cast or IM nail;
          - avg. time to union w/ IM nail was 18 weeks vs 26 weeks with a cast;
          - non-union occur in 2% of IM nail patients vs 10% in casted patients;
          - 26 of 47 patients requested that the IM nail be removed;
          - IM nail group had higher Iowa knee and ankle evaluation rating system scores than casted group;
    - references:
           - Treatment of tibial fractures by reaming and intramedullary nailing.
           - Interlocking nailing of complex fractures of the femur and tibia
           - Critical analysis of results of treatment of 201 tibial shaft fractures
           - Displaced isolated fractures of the tibial shaft treated with either a cast or IM nailing. An outcome with analysis of matched pairs of patients.
           - The use of the Lottes nail in the treatment of closed and open tibial shaft fractures.
           - Conservative management or closed nailing for tibial shaft fractures. A randomised prospective trial.
           - Locked intramedullary nailing for displaced tibial shaft fractures
           - Infection after intramedullary nailing of the tibia. Incidence and protocol for management.
           - Diagnosis and management of infection after tibial intramedullary nailing.
           - Unstable fractures of the tibia treated with a reamed intramedullary interlocking nail.
           - Radiographic analysis of tibial fracture malalignment following intramedullary nailing.
           - Comparison of functional bracing and locked intramedullary nailing in the treatement of displaced tibial shaft fractures.


- Use of IM Nails in Open Fractures: (see open tibial frx and exchange nailing)
    - references:
           - The use of the Lottes nail in the treatment of closed and open tibial shaft fractures.
           - Locked intramedullary nailing of open tibial fractures.
           - Treatment of open fractures of the tibial shaft with the use of interlocking nailing without reaming.
           - Infection after intramedullary nailing of the tibia. Incidence and protocol for management.
           - Diagnosis and management of infection after tibial intramedullary nailing.
           - Prospective study of union rate of open tibial fractures with locked unreamed intramedullary nails.
           - Closed intramedullary tibial nailing: its use in closed and type I open fractures.
           - Lower infection rate after interlocking nailing in open fractures of the femur and tibia.



Treatment of infected non-unions and segmental defects of the tibia with staged microvascular muscle transplantation and bone-grafting.

Treatment of unstable tibial shaft fractures by closed intramedullary nailing with flexible (Ender-type) pins.

Locked nailing for nonunion of the tibia.

Open intramedullary nailing and bone-grafting for non-union of tibial diaphyseal fracture.

The use of Ender nails in fractures of the tibial shaft.

The treatment of 143 tibial shaft fractures by Ender's nailing and early weight-bearing.

Flexible medullary nailing of acute tibial shaft fractures.

The timing of flap coverage, bone-grafting, and intramedullary nailing in patients who have a fracture of the tibial shaft with extensive soft-tissue injury.

Validation of a standardised gait score to predict the healing of tibial fractures



Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Thursday, August 2, 2012 1:47 pm