- General Discussion of IM Nails:
- PreOp Planning:
- positioning:
- cautions:
- proximal tibial fractures: (high complication rate w/ IM nailing)
- distal tibia fracture:
- IM nailing of open tibial fractures
- segmental tibia fractures:
- compartment syndrome:
- w/ IM nailing, posterior cortex of the tibia may be frxed on insertion of nail w/ possible nerve or vascular injury in posterior compartment;
- narrow intramedullary canal;
- references:
- Heat-induced segmental necrosis after reaming of one humeral and two tibial fractures with a narrow medullary canal.
- tourniquet:
- a tourniquet may aid exposure but is avoided with aggressive reaming, as absence of blood flow increases the extent of thermal necrosis;
- tourniquet may contribute to compartment syndrome and thermal necrosis;
- reference:
- The use of a tourniquet when plating tibial fractures.
- Thermal necrosis after tibial reaming for intramedullary nail fixation. A report of three cases.
- anesthesic considerations:
- surgeons should insist on general anesethesia or short spinal so that the surgeon can evaluate for postoperative compartment syndrome;
- references:
- Does patient controlled analgesia delay the diagnosis of compartment syndrome following intramedullary nailing of the tibia?
- Differences in attitudes to analgesia in post-operative limb surgery put patients at risk of compartment syndrome.
- Compartment syndrome without pain!
- Silent compartment syndrome complicating total knee arthroplasty: continuous epidural anesthesia masked the pain.
- Patient Position and Fracture Reduction:
- before the case starts, the surgeon should have a plan to obtain frx reduction, noting the amount of help and equipement available;
- figure of four position:
- same as the arthrscopic position, with hip and knee flexed over the opposite leg;
- minimzes the angulatory displacement in the saggital plane;
- note that once the proper entry hole is established (AP view), the reduction on the lateral view is most important;
- w/ proximal or distal fractures, consider need for blocking screws;
- w/ open fractures (or cases in which a fasciotomy has been performed) a direct reduction is performed thru the wound;
- direct reduction is often critical for proximal fractures;
- if the reduction is difficult to achieve, then a cannulated nail system should be used (both for reaming and for nail insertion);
- references:
- Does open reduction increase the chance of infection during intramedullary nailing of closed tibial shaft fractures?
- A positioning technique for closed intramedullar nailing of tibia fractures.
- Preparation for Nail Insertion: (see
synthes)
-
skin incision and exposure:
-
entry into the IM canal:
-
reaming of tibial fractures:
- over-reaming by 0.5 to 1 mm is probably indicated for all tibial IM nailing procedures since it helps
guarantee proper nail diameter (avoiding nail incarceration and/or posterior cortex blow out);
- the tourniquet should never be inflated during reaming of the intramedullary canal, since this risks thermal necrosis;
- avoid eccentric reaming:
- remember that the reamer follows the position of the guide wire and that the nail follows the path left by the reamer and therefore the guide wire position
needs to be carefully checked during reaming to make ensure that it is centrally located on two radiographic views;
- eccentric reaming will cause the nail to enter into the canal eccentrically which will end up cause the distal fracture fragment
to move into varus if the reaming is eccentric laterally and will cause it to move into valgus if the reaming is too medial;
-
determine nail width:
- this is a critical step because under-sizing the nail diameter will give a loose fit and over-sizing the nail may cause nail incarceration and resultant posterior cortex frx;
- reaming is the best way to determine nail width;
- w/ unreamed technique, sounds can be used to determine the diameter of the canal and the proper nail size;
- largest sound that passes easily thru the isthmus is correct choice;
- uncomminuted distal fractures may require a smaller diameter nail or reaming, as compared to comminuted isthmus fractures,
because of long interference fit within the canal;
- references:
Fatigue failure in small diameter tibial nails.
-
determine nail length:
- this is best determined once the initial starting reamer is placed down the canal;
- w/ the reamer down the canal, the fracture can usually be reduced no shortening or angulation;
- use flouro to mark proximal entry position at level of tibial plateau, & distal position at physeal scar;
-
radiolucent ruler:
- measures the proper nail distance;
- remember that if the ruler is placed on top of the tibia (rather beside it), then there will be a tendency to undersize length;
- pitfalls:
- do not measure nail length from the proximal tibial joint line but instead measure length from the nail entry site;
- often nail ends up being too short which can make insertion of distal interlocks more difficult since they will then be inserted thru hard cortical bone;
- Insertion of Nail:
- see considerations in proximal tibial fractures:
- prior to nail insertion, test the proximal interlocking device to ensure that the drill will pass w/o difficulty;
- if a canulated nail is being inserted, ensure that the ball tipped guide wire has been exchanged for the straight non-ball tipped guide wire;
- do not allow the nails to touch the skin as it is being inserted.
- check the nail progression:
- as the nail is hammered down the canal, its progression needs to be followed on the lateral view;
- if the nail fails to advance with each blow of the hammer, stop, for the nail is impinging on the cortex or it too large for the canal;
- attempts to drive it further may fracture the cortex;
- although the nail may occassionally too large, the usual cause for impingement is improper alignment of the nail within canal;
- fracture reduction: (completed as soon as the nail crosses the fracture site);
- ref: Does open reduction increase the chance of infection during intramedullary nailing of closed tibial shaft fractures?
- rotational alignment:
- once the nail crosses the fracture site, great care must be taken to restore rotational alignment;
- use flouro or the bi-malleolar axis to determine proper alignment;
- nail centralization:
- as the nail is driven thru the proximal fragment, it is important that it centralizes prior to reaching the fracture site;
- if nail does not centralize prior to reaching fracture site, then remove nail, re-ream the canal, and consider adding a posterior bicortical blocking screw;
- fracture compression:
- once the nail is across the fracture site, place counter pressure across the foot to provide frx compression as the nail is driven distally;
- Interlocking:
- proximal inter-locking:
- distal interlocking: prior to distal interlocking, ensure that there is optimal frx site compression;
- two screws should be used if the position of the screws is within 4 cm from the fracture site;
- Post Operative Care:
- if stability of the fracture is in question, then below knee cast immobilization and touch down wt bearing are used until healing;
- once partial fracture healing has taken place, consider a functional brace or consider a below knee cast with the dorsum of the foot
and ankle removed to allow ankle dorsiflexion;
- active dorsiflexion and plantarflexion stresses the tibia and produces displacements similar to wt bearing;
- static locking: most tibial fractures heal in the static locked mode;
- dynamization:
- removal of proximal or distal screws allows axial loading of tibia;
- consider at 3 months in axially stable fractures with no callus;
- axially unstable frx should remain in static mode and should receive bone grafting;
- Complications:
- non-union
- probably the biggest risk factor for tibial non union following IM nailing is fracture mal-position or the presence of a gap at the fracture site;
- anterior knee pain:
- references:
- Anterior knee pain and thigh muscle strength after intramedullary nailing of tibial shaft fractures: a report of 40 consecutive cases.
- Incision placement for intramedullary tibial nailing: an anatomic study.
- Anterior knee pain after intramedullary nailing of fractures of the tibial shaft.
A prospective, randomized study comparing two different nail-insertion techniques.
- Percutaneous intramedullary nailing of tibial shaft fractures: a new approach for prevention of anterior knee pain.
- Knee pain after intramedullary tibial nailing: its incidence, etiology, and outcome.
- Knee pain after tibial nailing.
- compartment syndrome:
- references:
- Compartment syndrome without pain!
- infection: (see infections following tibia fracture)
- if nail removal is required, then consider reaming canal after nail removal as a method of debridement;
- see addition of antibiotics to cement
- references:
- Infection after intramedullary nailing of the tibia. Incidence and protocol for management.
- Diagnosis and management of infection after tibial intramedullary nailing.
- Infection after reamed intramedullary nailing of the tibia: a case series review.
- Intramedullary infections treated with antibiotic cement rods: preliminary results in nine cases.
- The antibiotic cement nail for infection after tibial nailing.
- Antibiotic Cement-Coated Interlocking Nail for the Treatment of Infected Nonunions and Segmental Bone Defects.
- dropped hallux deformity:
- in report by Robinson CM et al. (JBJS Br 1999 May;81(3):481-4) authors performed a prospective study of 208 patients w/ tibial frx treated by reamed IM nailing;
- 11 (5.3%) developed dysfunction of peroneal nerve with and 8/11 showed a 'dropped hallux' syndrome, with weakness of EHL and numbness in
first web space, but no clinical involvement of extensor digitorum longus or tibialis anterior;
- there was good recovery of muscle function within 3-4 months in all cases, but after one year 3 patients still had some residual tightness
of EHL, and two some numbness in the first web space.
- references:
- Radiographic analysis of tibial fracture malalignment following intramedullary nailing.
- Severe heterotopic bone formation in the knee after tibial intramedullary nailing. P. Tornetta and P. Barbera. J. Orthop. Trauma. Vol 6. p 113-115. 1992.
