Tibial Shaft Fracture IM Nail 27759

synonyms: tibial shaft fracture intramedullary nail, IM nail

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)

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

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.

Tibial Shaft Fracture IM Nail Alternatives

Tibial Shaft Fracture IM Nail Pre-op Planning

• Review manufacture technique guide: does nail fit over ball-tip guidewire. What size are the proximal and distal locking screws for the chosen nail diameter. What size must the tibia be reamed to proximally. Example: Biomet low profile tibial nail=2 M/L prox screw, 2m/l distal screws, 1A/P distal screw. 8-12mm nails must have prox 6cm reamed to 12mm.  13-14mm ream 1mm over proximally.  Prox screw=4.3mm drill, 5.0screws.  Distal screws=3.6mm drill/4.0mmscrew for 8&9mm nails, 4.3mmdrill/5.0mm screw for 10mm+nails
• Reamed nails for closed fxs have slightly higher healing rate and less hardware failure(locking bolts) than undreamed nails.  NO difference in malunion, infection, compartment syndrome, or knee pain.-OKU-7
• Discuss postoperative knee pian the patients pre-operatively.
• For Proximal 1/3 fractures see Proximal Tibial Shaft IM Nail Technique.
• Distal 1/3 fractures: reduce and fix and intraarticular extension with lag screws prior to nail insertions. ORIF any associated fibula fracture prior to IM nailing.
• Consider primary graft vs rhBMP-2 for osseous defects.
• Im Nailing may be done on a fracture table or supine. Reduction of the fracture can be achieved with the fracture table, large femoral distractor, temporary two pin traveling traction, or use of an assistant / triangles.
• 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)
• See Open Fracture.
• Case Card.

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.
• 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.
• 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.
• Remove jig
• Evaluate nail placement proximally, distally and at fracture site using c-arm.
• Irrigate.
• Close in layers.
• Apply bulky Jones dressing with posterior mold to avoid equinus contracture.

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

• Rockwood and Greens
• Master Techniques in Orthopaedic Surgery: Fractures
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