- Indications:
     - tibial shaft fractures within 4 cm distal to the tibial tuberosity to 4 cm proximal to the ankle may be treated with interlocking techniques;

- Soft Tissue Injury:
     - open tibial frx (Gustillo classification):
     - reconstruction for leg defects:

- Frx Stability:
    - see Winquist classification:
    - fracture is stable with at least 50% of cortical continutiy and within the middle 1/3 of the tibia
    - when stability is in doubt, static interlocking allows control of alignment, length, and rotation (esp. rotation);

- Exam:
    - compartment syndrome:
         - note, w/ IM nailing, posterior cortex of tibia may be frxed on insertion of nail w/ possible nerve or vascular injury in deep posterior compartment;
    - MCL tears are common and PCL may be injured in about 5 %;

- Templating:
    - length:
         - measuring length of nail is simple, a tape measures the length from medial malleolus to tibial tuberosity on unaffected side;
                - nail should come w/in 2 cm of articular surface at distal end of tibia to provide for maximum fixation;
         - overlie tibial nail template on the AP and lateral radiograph to help determine optimal nail entry position;
         - intraoperative determination:
                - use flouro to mark proximal entry position at level of tibial plateau, & distal position at physeal scar;
                - pitfalls: do not measure nail length from the proximal tibial joint line but instead measure length from the nail entry site;
         - use radiographic ruler on the reduced leg or on the contralateral leg;
    - rotational alignment:
         - use opposite leg as a reference for rotational alignment;

- Positioning for Tibial IM Nailing

- Difficult Fractures:
    - proximal tibial fractures
    - fractures w/ long anterior spike
         
          - in this case, the fracture was left malreduced (and w/ poor bony opposition) and only a single proximal interlocking screw;
          - after 4 months, the proximal interlocking screw broke, the fracture shortened, and the long anterior spike caused tenting of the skin

Study finds 47% primary union rate in tibia patients with ‘critical-sized’ bone defects