synonyms: tibial shaft fracture intramedullary nail
Proximal 1/3 Tibial Shaft Fracture IM Nail CPT
Proximal 1/3 Tibial Shaft Fracture IM Nail Indications
- high-energy fx
- modereate to severe soft-tissue injury
- unstable fracture pattern->5coronal angulation, >10sagittal angulation, >5rotation, >1cm shorteing
- open fx
- compartment syndrome
- ipsilateral femur fx
- inability to maintain reduction
- intact fibula
Proximal 1/3 Tibial Shaft Fracture IM Nail Contraindications
- Severely contaminated open tibial shaft fracture
- External fixator with pin site infection
- External fixator in place >2 weeks (relative)
- Articular comminution: Consider ORIF vs Ilizarov.
Proximal 1/3 Tibial Shaft Fracture IM Nail Alternatives
Proximal 1/3 Tibial Shaft Fracture IM Nail Pre-op Planning
- Proximal fractures have strong tendency towards anterior displacement of proximal fragment and valgus alignment.
- Consider lateral starting point, provisional anteromedial unicortical plating or blocking screws.
- Reamed nails for closed fxs have slightly higher healing rate and less hardware failure(locking bolts) than unreamed nails. NO difference in malunion, infection, compartment syndrome, or knee pain.
- Discuss postoperative knee pian the patients pre-operatively.
- See Open Fracture.
- Case Card.
Proximal 1/3 Tibial Shaft Fracture IM Nail Technique
- Sign operative site.
- Pre-operative antibiotics, +/- regional block.
- General endotracheal anesthesia
- Supine position on radiolucent fracture table. All bony prominences well padded.
- Ensure adequate C-arm images can be taken in A/P and lateral planes.
- Prep and drape in standard sterile fashion.
- Place 2-pin traveling traction external fixator to reduce fracture and maintain reduction.
- Varify reduction. Rotation can be assess by ensuring that the second toe aligns with the tibial tuberosity.
- Use bovie cord to determine entry site-proximal(just distal to articular surface) and lateral generally in line c lateral intercondylar eminence.
- Longitundinal or transverse 2-3cm incision
- Dissection medial to patellar tendon.
- Make starting point with awl. Sagittal plane entry point parallel to the anterior cortex of the proximal fragment
- Place ball-tiped guidewire across fracture site.
- Ream in 0.5cm increments to 1.5mm greater than selected nail size.
- Measure nail length off guidewire.
- Blocking Screws: Consider for fractures with short proximal or distal fragments. Screw is placed in the short fragment, close to the fracture, on the concave side of the axial deformity.(Stedtfeld H JBJS 2004;86A supplement 2,:17)
- Place selected nail.
- Remove guide wire
- Place distal locking screws using freehand technique.
- Back slap the nail to compress the fracture site and eliminate any distraction which occured during nail placement.
- Place proximal locking screws using targeting jig. Consider proximal interlocking with knee in extension.
- Remove jig
- Evaluate nail placement proximally, distally and at fracture site using c-arm.
- Irrigate.
- Close in layers.
Proximal 1/3 Tibial Shaft Fracture IM Nail Complications
Tibial Shaft Fracture IM Nail Follow-up care
- Post-op: Apply bulky Jones dressing with posterior mold to avoid equinus contracture. Elevate. Consider DVT prophyaxis.
- 7-10 Days: Remove splint, wound check. WBAT, PT, knee, ankle mobilization based on fracture stability / soft tissues.
- 6 Weeks: Xrays. Advance PT
- 3 Months: Xrays. Consider bone stimulator/nail dynamization if union is not evident. Sport specific PT.
- 6 Months: Return to full activities
- 1Yr: follow-up xrays, asssess outcomes.
Tibial Shaft Fracture IM Nail Outcomes
Tibial Shaft Fracture IM Nail Review References
