Distal Interlocking for Tibial IM Nails

- Technique:
    - while obtaining a perfect circle under flouroscopy it is important not to rotate the foot because this will cause a malalignment of the foot progression angle;
            - instead, rotate either the entire leg as a unit or the flouro machine to achieve a perfect circle;
    - drill / screw insertion may be performed in a medial to lateral or a lateral medial direction;
            - advantage of lateral to medial direction is ease of insertion (because the opposite leg does not get in the way), and decreased prominence of screw head;
                   - disadvantages include possible injury to the anterior tibial artery on entry (especially if nail is short) and superficial peroneal nerve;
                   - note however, the ATA and SPN can be just as easily injured upon perforation of the opposite cortex from the M-L direction;
            - ref: Should distal interlocking of tibial nails be performed from a medial or a lateral direction? anatomical and biomechanical considerations.
    - place the tip of the drill bit oblique to the X-ray beam into the stab incision and onto the tibia until the tip of the drill bit is centered in the locking hole;
    - since the holes through the nail weaken it significantly, no hole must be at the fracture level or left empty if near the hole;
    - references:
            - Single or double distal locking in intramedullary nailing of tibial shaft fractures: a prospective randomized study
            - The effect of distal screw orientation on the intrinsic stability of a tibial intramedullary nail.
            - How many distal bolts should be used in unreamed intramedullary nailing for diaphyseal tibial fractures?

- Complications:


Fatigue failure in small diameter tibial nails.

Mechanical failures of intramedullary tibial nails applied without reaming.

Interlocking Intramedullary Nailing with and without Reaming for the Treatment of Closed Fractures of the Tibial Shaft. A Prospective, Randomized Study.

Locking Intramedullary Nailing with and without Reaming for Open Fractures of the Tibial Shaft.  A prospective, randomized study.

Pseudoaneurysm After Tibial Nailing.

Impact of posterior tibial nail malpositioning on iatrogenic injuries by distal medio-lateral interlocking screws. A cadaveric study on plastinated specimens.

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

Last updated by Clifford R. Wheeless, III, MD on Monday, May 27, 2013 7:09 pm