Flexible Intramedullary Nailing Tibia
Craig M. Birch, MD
Indications
Displaced diaphyseal tibial fracture
Ipsilateral femur fracture requiring surgery
Unable to obtain/maintain closed reduction with casting
Length stable fracture pattern (transverse, short oblique)
Ages: open proximal tibial physis
Sterile Instruments/Equipment
Titanium flexible nail set
Radiolucent flat table
Tourniquet
Radiolucent tibial triangle
Patient Positioning
Supine on the radiolucent table with tourniquet (Figure 25-1)
Check rotation of uninjured side prior to proceeding by assessing the line drawn from the tubercle to foot with most patients’ alignment having the tubercle to foot line being at the second ray
Bump underneath ipsilateral buttocks to prevent patient external rotation
Contralateral leg lower to aid in radiographic lateral imaging
Avoid malrotation by placing the hip and the knee cap to the ceiling. Look longitudinally from the foot and the limb position of the anterior hip and anterior knee should match and make sense. Significant internal or external rotation of the foot and the distal fracture should be a cause of concern and reevaluation.
Complete fluoroscopic AP and lateral views at the knee, fracture, and ankle to assure ability to visualize tibia completely and obtain provisional reduction.
Surgical Approaches
Proximal exposure with placing nails from proximal to distal is best for tibia shaft fractures (Figure 25-2).
Nails placed from each side of tibia
Incision (2 cm) centered over the lateral and medial sides of proximal tibia at the midline level sagittally.
Figure 25-1 ▪ Clinical photo showing intraoperative positioning for flexible nailing.
Figure 25-2 ▪ Radiograph demonstrating correct proximal position of nails.
Incision should be starting at the level of physis and extending 2 cm distally
Medially may have to make a sagittal split in pes anserinus and dissect down to tibia (Figure 25-3). Laterally will have to dissect small amount of proximal anterior compartment muscle away from tibia.
Reduction and Fixation Techniques
Nail diameter is generally 3.5 mm or 4.0 mm, sized for 80% canal fill at the isthmus. It is best to use the same diameter nails to avoid a dominant side nail, misaligning the fracture.
The nails should have a 30° arc of bend as well as a bend in the direction of the tip in the entry side of the nail to facilitate the curved path from entry into the metaphysis and intramedullary canal
The starting point of the nail is generally 2 cm below the physis and in the midline. A 3.2 mm drill bit is used to obtain the starting point. The drill should start perpendicular to the tibia and once the cortex is perforated, it should be used in a back and forth manner to eventually change the angulation; so it is headed 45° caudal. An awl may be used to expand the hole(Figure 25-4).
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