Proximal Tibial Shaft Fracture 27759

 

synonyms: tibial shaft fracture intramedullary nail

Proximal 1/3 Tibial Shaft Fracture IM Nail CPT

  • 27759 (treatment of tibial shaft fractur with or without fibular fracture with intramedullary implant, with or without interlocking screws and/or cerclage)

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

  • External Fixation
  • Amputation
  • Casting / Functional Brace
  • ORIF
  • Ring / Ilazarov fixator

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

  • Knee pain
  • Malunion
  • Nonuion
  • Infection
  • Painful hardware
  • Compartment Syndrome
  • CRPS
  • DVT / PE

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

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