Nailing of distal tibia fractures has several advantages compared to conventional plating. Though stripping of the periosteum and additional soft tissue damage can be reduced with minimally invasive plating [2], this can be completely avoided with a nailing procedure. Due to critical blood supply in the region of the distal lower leg, patients with comorbidities like venous insufficiency, peripheral arterial disease, diabetes or smokers are prone to soft tissue and bone healing problems. In this setting nailing may be more advantageous as it minimizes further soft tissue damage.

In the presence of soft tissue defects due to skin loss from wound breakdown or primary loss after debridement in open fractures, fixation with an intramedullary nail prevents exposure of the implant in the wound. In such a setting an extra-medullary implant is not an ideal solution though there is a possibility of soft tissue coverage with plastic measures. Any soft tissue breakdown will leave the implant exposed. For this reason, we prefer nailing also in third degree open fractures [3].

An intramedullary implant that is statically locked functions as a load bearing implant. When the nail is dynamized, it functions as a load sharing implant in the presence of cortical contact. Hence, when the nail is placed accurately in the mechanical axis of the leg (anatomical axis of tibia), weight bearing is possible immediately in a stable fracture configuration. This is not possible with an extramedullary implant in a similar fracture configuration.

Though nailing has many advantageous, there are several challenges that warrants a brief discussion. First, a healthy and large enough bone stock is necessary to securely place two or better three locking screws. The last generation nails provide locking options in three planes. In distal tibia fractures however, there is a limit to the extent the nail can be advanced distally and accordingly placement of the number of distal locking screws may be limited by the proximity of the fracture. In this situation, the use of angular stable locking screws can enhance stability. They have a large diameter near the screw head and a bioresorbable sleeve that expands in the drill hole of the nail when the screw is inserted (Fig. 23.2a–j). In biomechanical studies and in animal models, interfragmentary movement has shown to be reduced and bone healing accelerated [4–6]. Nevertheless, clinical studies to prove these findings in distal tibia fractures are lacking.

Primary or secondary malalignment are well known complications of distal tibia nailing [7–10]. It can be difficult to control the small distal fragment and to maintain the alignment during nail insertion. There is a mismatch between the small intramedullary canal in the diaphysis and the broad metaphyseal plafond. A distal tibia fracture will not be reduced during nail insertion as is the case in a shaft fracture. Reduction must be achieved before entering the nail in the distal fragment. Once the nail is propagated through the fracture site, it forms a track in the distal metaphyseal bone. It is difficult to correct the pathway of the nail in the distal fragment if a false track has been created primarily. In such a situation intramedullary blocking screws (poller screws) or K-wires to block the preformed track will be required [11].

In the treatment of distal metaphyseal fractures, correct reduction must be achieved before the nail is inserted in the distal fragment. No improvement of reduction can be achieved via the nail itself, as it is possible in diaphyseal fracture types [10]. Depending on the fracture type, closed reduction of the fragments may already be performed before preparation of the approach. We have various reduction aids at our disposal. In rotational fractures tibia length and rotation may be restored through simple axial pull on an extension table. Additionally, fragments can be reduced manually through pressure and rotation. Some simple fractures will lock into place through careful release of extension. If the fracture is less stable and a valgus deformation appears after manual reduction, this may be corrected by pulling laterally at the fracture site using a sterile cloth. This has the advantage of avoiding radiation exposure of the surgeon’s hands during nail insertion. In many cases anatomic reduction may be achieved and secured using one or more pointed reduction forceps. As an alternative method to the extension table, an AO-distractor may be used. Schanz’ screws are inserted proximal dorsally and distal centrally and the fracture is reduced through traction and direct manipulation. An advantage of this method is free movement of the knee joint allowing more flexion when the nail is inserted and full extension while the distal locking screws are put into place. The same can also be achieved with an external fixator. The distal pin may alternatively be inserted into the calcaneus. Using these methods a free lateral view of the distal tibia and ankle joint in the image intensifier must be ensured.

If the fracture involves the joint line, anatomic reduction of the joint block must first be achieved using pointed reduction forceps as shown in Fig. 23.3a–c. Small anterior and posterior incisions are necessary and, where neurovascular structures are at risk, careful preparation to the bone is mandatory. Small fragment lag screws fix the articular fracture (Fig. 23.4a–f). Precise alignment and reduction of the distal tibia fracture is a prerequisite for intramedullary nailing and must be confirmed in two planes using the image intensifier. If perfect alignment cannot be obtained with these techniques, other types of reduction and (provisional) fixation (e.g. minimal invasive LCP-plate) must be chosen. After reduction of oblique or spiral fractures, percutaneously inserted screws may be used for fixation. Two screws are needed to neutralize rotational forces.

Correct reduction is also a prerequisite for exact measurement of the required nail length. A radiographic ruler is held next to the tibia. The proximal end of the nail is visualized flush with the ruler using image intensification. The image intensifier is then moved to the distal end and the required nail length can be read from the ruler. Alternatively nail length is measured using two guide wires once the approach has been done and the medullary canal has been opened. The first guide wire is inserted into its ideal position at the distal end of the tibia. A second guide wire of equal length is used in order to measure excess length. It is held next to the first, intramedullary guide wire so that the tip is flush with the envisaged proximal end of the nail. The overlapping length is marked with a clamp. The excess length corresponds to the intramedullary length and is measured using a ruler. Generally, a somewhat shorter nail should be chosen rather than the one that is longer than measured, as end caps are available to extend nail length if necessary. Additionally a possible diastasis at the fracture must be taken into account that will be reduced using a “backstroke technique”. A nail that is too long may cause knee pain and may necessitate revision surgery. A nail that is too short may only cause problems in implant removal surgery besides the issue of a shorter working length.

For skin incision the following landmarks should be identified: Tip of the patella, patellar tendon, tibia tuberosity, tibia crest, tibia plateau. Longitudinal incision of the soft tissues above the patellar tendon is done along the imagined proximal extension of the tibia crest. The patellar tendon may be split longitudinally or a medial parapatellar approach may be chosen. Depending on the patient’s anatomy, even a lateral parapatellar approach may be necessary.

The correct entry point for intramedullary nailing of the tibia is at the edge of the tibia plateau in the lateral view and in line with the lateral intercondylar eminence and the intramedullary canal in the anteroposterior view [12]. The optimal location of the entry portal is checked by image intensifier in exact anteroposterior view (showing an overlap between the fibular head and the tibia of about 50 %) before using the cutting tool. If provided by the manufacturer a guide wire for the cutting tool is inserted at a sagittal angle of 10° to the tibia axis into the intramedullary canal. This angle allows introduction of the nail without hitting the posterior cortex in the shaft. In doubt image intensification must be used to exclude posterior cortex perforation.

After creating the entry portal, the guide wire for reaming is inserted. The positioning of the guide wire in the distal fragment determines the location of the nail after reaming and must therefore be chosen carefully. Reaming must be performed using sharp reamer heads in 0.5 mm increments and position of the fracture fragments must constantly be verified. The smallest reamer head should be used at the beginning. It is important not to ream distal to the isthmus not to remove cancellous bone in the distal fragment. Otherwise the stiffness of the nail-bone construct is reduced. The most commonly used nails have a diameter of 9 mm or 10 mm [13] and so reaming should be performed to 10 mm or 11 mm respectively. The chosen nail with corresponding length and thickness is now inserted into the medullary canal under axial pressure and slight rotational movements. If this is not possible by hand, gentle hammering may be used while reduction must be maintained as the nail passes the fracture site. Fracture reduction is verified with the image intensifier in two planes when the nail is in place.

If reduction could not be maintained during insertion of the nail and the nail could not be positioned with correct alignment, it must be withdrawn above the fracture site. There is now a tunnel in the distal fragment that causes the nail to find the same position again and again in successive attempts. This may be prevented by placing an intramedullary blocking screw (poller screw) [11]. The misleading tunnel is blocked by this implant and the nail is forced into the correct position as shown in Fig. 23.5a–c. The position of this blocking screw must be chosen wisely so that it will not interfere with the distal locking screws.

An alternative and easier method is the use of K-wires. K-wires with a diameter of 1.8–2 mm are used instead of Poller screws (Fig. 23.6a–d). This may be faster because tapping, measuring screw length, finding the hole and inserting the screw is no longer necessary. It is also easier to re-position the K-wire if the location of the nail could not be satisfactorily corrected. Biewener et al. [14] presented a method by which the nail is guided along a palisade of K-wires. It is published for use in cases with malalignment after intramedullary nailing (Fig. 23.7a–g). In principle, it also may be used during the primary nailing procedure.

After the nail has been inserted, distal interlocking is done. A radiolucent drive is helpful. While it is usually sufficient to use double interlocking at the proximal and distal end in shaft fractures, maximum stability must be aimed at in distal fractures. Depending on the fracture site, as many locking options as possible should be used in order to reach a stable construct against forces with a long lever arm. First, the guide wire is removed to clear the interlocking holes of the nail. Viewed through the image intensifier, the locking hole must be perfectly circular. When this has been achieved, the scalpel blade must cover the locking hole in order to identify the correct location of the incision. A sufficiently long incision should be made to allow for careful soft tissue preparation until the surface of the bone has been reached (Fig. 23.8). The drill bit is then placed obliquely onto the cortex in order to verify the correct position of its tip above the locking hole. Next the radiolucent drive is tilted so that the drill bit appears as a circular point within the hole. A bicortical hole is now drilled and its length measured.

After distal locking has been completed the fracture gap must be reevaluated. A diastasis may have occurred after insertion of the nail. This lengthening of the tibia must absolutely be avoided. On one hand it may increase the risk for the development of a compartment syndrome [15] and on the other hand a remaining fracture gap of more than 3 mm is an important factor leading to delayed bone healing or nonunion [16]. This problem may be solved using the so-called “back stroke technique”. When using an extension table, the extension is now loosened. Equally, when using a distractor or external fixator, the tension must be released. A guiding rod is screwed onto the insertion handle. Now, using a hammer, gentle backward blows can be administered as if trying to remove the nail again from the medullary canal. This closes the fracture gap and must be verified radiographically (Fig. 23.7d, f, g). If too much force is used, malalignment or iatrogenic fractures may occur. Finally, proximal locking is done through the insertion handle that is still in place. For treating distal fractures, two-fold medial-lateral locking is done proximally. Finally, an end cap should be inserted to prevent tissue ingrowth and therefore facilitate potential future nail removal. After 4–6 weeks, the proximal static screw(s) can be removed to achieve a dynamization at the fracture gap, if necessary. When the patient is ambulating a controlled axial compression by partial weight bearing is allowed, which assists bone healing.

A guideline for postoperative treatment is given in Table 23.2.