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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
                   shaft of 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;
          - references:
                   - Intramedullary Nailing and Angulation Prevention in Distal Metaphyseal Tibial Fractures
                   - Effect of distal interlocking screw number and position after intramedullary nailing of distal tibial fractures: a biomechanical study simulating immediate weight-bearing.

    - 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 fractures: 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 frx of the tibia with minimal involvement of the ankle. Classification and treatment by locked IM.

- 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].
  - Plate versus nail for distal tibial fractures: a systematic review and meta-analysis.