Distal Tibial Fractures: Technique of IM Nailing : Wheeless' Textbook of Orthopaedics

- 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;

      - 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;