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Duke Orthopaedics
Wheeless' Textbook of Orthopaedics

Distal Tibial Fractures: Technique of IM Nailing   

- See: 
      - IM nailing of tibia fractures - menu
      - tibial plafond fractures

- Distal Tibia Fracture:
    - see: external fixation for distal tibia fracture, outcomes of external fixation vs IM nailing, and plate fixation;
    - w/ frx extension into the joint, consider placement of percutaneous lag screws to repair intra-articular fracture lines before nailing is performed; 
    - guide wire:
guide wire needs to be directed towards the medial malleolus while the ankle is held in valgus;
          - this will minimize the tendency for the fracture to drift into varus as the nail passes across the fracture site;
    - blocking screws:
          - antero-posterior blocking screws are inserted on either side of the central nail insertion zone inorder to effect an anatomic reduction; 
          - in general, the blocking screw is positioned where you don't want the nail to go;
          - blocking screws are temporary, and therefore can be left 2 cm longer than needed for easy removal;
          - with fracture demonstrating preoperative varus displacement, consider an antero-posterior blocking screw inserted on medial side of  distal fragment; 
                    - this screw can be biased also in a medial to lateral direction to correct the recurvatum malreduction, or alternatively, a second blocking screw,
                             inserted from a medial to lateral direction in the anterior third of the tibia can be placed;

          - blocking screw should remain as peripheral as possible (minimal blockage) in order to prevent iatrogenic comminution of distal fragment at opposite end of frx;
          - consider insertion of tip of nail 1 cm past frx site (barely across), and then inserting the blocking screw at a point tangential to the shaft of
                   the nail at same level as the tip of the nail (1 cm);
                   - as the nail is advanced the shaft will contact the blocking screw;



    - need for 2 proximal and 2 distal interlocking screws;
          - in the study by Isik, et al (2012), the authors performed IM nailing with 2 distal and proximal screws on 34 patients, with no post op complications;
          - ref: Intramedullary Nailing and Angulation Prevention in Distal Metaphyseal Tibial Fractures
    - transfibular blocking screw (as a temporary means of achieving reduction)
          - instead of the classic blocking technique, a much easier technique involves percutaneous insertion of a 4.0 or 5.0 screw inserted through the fibula;
          - using percutaneous technique, insert a screw across the fibula until it engages the tibia.
          - additional passage of the transfibular screw will begin to translate the distal tibial fracture site in medial direction;
          - screw is advanced until it abuts the tibia, and then it is further advanced until the reduction is optimal;
          - with soft bone, the screw may penetrate the cortex, but this is OK, because the screw will then continue to act as a blocking screw against the nail;
          - a second screw (inserted below the first screw) may also be required inorder to optimize the reduction;
          - once the nail has been inserted and once interlocking screws are in place, the transfibular screws can be removed;


    - ORIF of distal fibula:
          - some authors recommend concomitant ORIF of the distal fibula (if frx is present), inorder to improve rotational stability; 
          - 85 % of patients with malalignment after nailing do not have fibula fixation;
          - there is some evidence (Attal R, et al), that fibular fixation may lead to delayed union (8 fold higher risk of delayed bone healing); 
          - references:
                 - Effect of Fibular Plate Fixation on Rotational Stability of Simulated Distal Tibial Fractures Treated with Intramedullary Nailing.
                 - Does Fibular Plating Improve Alignment After Intramedullary Nailing of Distal Metaphyseal Tibia Fractures? 
                 - The effect of concurrent fibular fracture on the fixation of distal tibia fracture: a laboratory comparison of intramedullary nails with locked plates
                 - Fibular fixation as an adjuvant to tibial intramedullary nailing in the treatment of combined distal third tibia and fibula fractures: a biomechanical investigation.
                 - Distal leg fractures: How critical is the fibular fracture and its fixation?
                 - Distal quarter leg fractures fixation: The intramedullary nailing alone option
                 - Randomized, Prospective Comparison of Plate versus Intramedullary Nail Fixation for Distal Tibia Shaft Fractures
                 - A multicentre case series of tibia fractures treated with the Expert Tibia Nail (ETN) 
                 - Distal tibial metaphyseal fractures: the role of fibular fixation
                 - [Intramedullary nailing of the distal tibia illustrated with the Expert(TM) tibia nail].

      - Management of Concomitant Articular Fracture:
            - see: restoration of articular anatomy in tibial plafond fractures;
            - ref: Distal metaphyseal fractures of the tibia with minimal involvement of the ankle. Classification and treatment by locked intramedullary nailing.

- Post Traumatic Claw Toes:
      - Selective lengthening of the proximal flexor tendon in the management of acquired claw toes

- Case example:

   82 year old male, who is about 5 weeks into cast treatment of a tibia fracture.  Because of pain, fracture malreduction, and inability 
   to maintain a cast, IM nailing is chosen.  The fracture was scarred into the malreduced position which required aggressive use of
   polar screws to get the nail into proper position;


- references:

  - Modified tibial nails for treating distal tibia fractures
  - Interlocking intramedullary nailing in distal tibial fractures.
  - Dia-metaphyseal distal tibial fractures--treatment with a shortened intramedullary nail: a review of 15 cases.
  - The unreamed tibial nail in the treatment of distal metaphyseal fractures.
  - Intramedullary nailing of unstable diaphyseal fractures of the tibia with distal intraarticular involvement.
  - Nonunions of the Distal Tibia Treated by Reamed Intramedullary Nailing.
  - Intramedullary Nailing of Distal Metaphyseal Tibial Fractures.
  - Treatment of Distal Tibia Fractures Without Articular Involvement: A Systematic Review of 1125 Fractures.
  - Treatment of distal tibial metaphyseal fractures: Plating versus shortened intramedullary nailing. 
  - Radiographic and Clinical Comparisons of Distal Tibia Shaft Fractures (4 to 11 cm Proximal to the Plafond): Plating Versus Intramedullary Nailing.
  - High association of posterior malleolus fractures with spiral distal tibial fractures
  - Extra-articular distal tibia fractures: a mechanical evaluation of 4 different treatment methods.
  - A prospective, randomised trial comparing closed intramedullary nailing with percutaneous plating in the treatment of distal metaphyseal fractures of the tibia.  
  - A randomised pilot trial of “locking plate” fixation versus intramedullary nailing for extra-articular fractures of the distal tibia
  - Distal tibia fractures: management and complications of 101 cases
  - [Evaluation of interlocking intramedullary nailing in distal tibial fractures and nonunions].
  - Intramedullary nailing of the distal tibia illustrated with the Expert(TM) tibia nail

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

Last updated by Data Trace Staff on Monday, September 8, 2014 9:27 am