29: Proximal Tibia Fractures: Intramedullary Nailing

PROCEDURE 29 Proximal Tibia Fractures: Intramedullary Nailing



Max Talbot, Greg K. Berry



image


Indications



image Extra-articular fractures of the proximal tibia

image Proximal tibia fractures with simple intra-articular extension



PITFALLS



• Fractures with significant tibial plateau involvement should not be treated by this method.

• The proximal fragment should be large enough to accommodate three proximal locking screws.

• There should be at least 4 cm of intact anterior tibial cortex in the proximal fragment to contain the nail.



Treatment Options



• Many nail systems are available. Choose a nail that will allow at least three proximal locking screws in different planes.

• Other options
image Percutaneous locked plating

image Hybrid external fixator

image Open plating (not preferred)


Examination/Imaging



image Detailed neurologic and vascular examinations, including an ankle-brachial index, are conducted.

image Soft tissue status and the presence of any open fractures should be determined.

image Compartment syndrome should be kept in mind.

image Anteroposterior (AP) and lateral radiographs of the entire tibia (Fig. 1A and 1B) are obtained.

image If there is any suspicion of articular extension, a computed tomography scan should be obtained.

image

FIGURE 1



Surgical Anatomy



image The entry point in the proximal tibia (Fig. 2A) can endanger the menisci, intermeniscal ligament, and articular surface (Fig. 2B).

image Use established radiologic landmarks to avoid injury to these structures.

image

FIGURE 2




PEARLS



• Prior to prepping and draping, preliminary C-arm images should be obtained to ensure that good visualization will be possible.



Equipment



• Adjustable triangular frame


Positioning



image The patient is positioned supine.

image An adjustable triangular frame is used to support the limb (Fig. 3A and 3B). This allows the knee to be supported in variable degrees of flexion during the procedure.

image When maximal flexion is needed, we find it easier to slide the leg off the triangular frame and have an assistant hold it in the desired degree of flexion. This is mostly useful for insertion of the entry reamer, to ensure that the reamer enters the metaphysis parallel to the anterior cortex of the tibia.

image

FIGURE 3



Portals/Exposures



image Either a transtendinous or a lateral parapatellar approach is recommended.

image Transtendinous
• This is the authors’ preferred approach for proximal tibia fractures.

• A skin incision is made centered on the patellar tendon, from the inferior pole of the patella to the tibial tubercle (Fig. 4).

• The patellar tendon is split to access the proximal tibia.

• This approach does not lead to more complications or to decreased functional outcomes compared to a parapatellar approach.

image Lateral parapatellar
• A small incision is made lateral to the patellar tendon (see Fig. 4).

• The tendon is mobilized medially.

image

FIGURE 4




PITFALLS



• With either approach, great care must be taken to protect the patellar tendon throughout the procedure, especially during reaming.



PEARLS



• The direction the entry reamer takes in the proximal segment is of critical importance.

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Jun 7, 2016 | Posted by in ORTHOPEDIC | Comments Off on 29: Proximal Tibia Fractures: Intramedullary Nailing

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