Skeletal traction with a traction table is widely used. Thanks to soft tissue attachment to the bone, ligamentotaxis will lead to alignment of the main fracture fragments. This alignment is very helpful, but not precise and stable enough. More precise alignment and better control of fracture reduction will be needed before the nailing procedure is started. In fractures with severe soft tissue damage, muscles are disrupted from the main fracture fragments. Skeletal traction therefore will only distract the fracture fragments and widen the fracture gap, but not realign the bone. A further limitation of the use of a fracture table is that the knee joint is fixed in 90° of flexion. Less or more flexion may be needed for uneventful nail introduction [23].

As an alternative to a fracture table, skeletal traction may be obtained with a modular distraction frame, a large distractor or an external fixator. The modular frame allows positioning of the leg with variable flexion of the knee joint [24, 25] (Fig. 21.3). Alternative reduction aids can be used separately or in addition to the extension table or distraction frame. On both sides of the fracture, Schanz’ screws can be drilled in one cortex and used as jockey sticks to control and adjust orientation and position of fracture fragments. A provisional reduction can also be obtained with the help of a bone hook. In oblique and spiral fractures, the fracture gap is closed with the help of a pointed reduction forceps or bone clamp. These instruments are inserted percutaneously or through small incisions. Perfect reduction and gap closure are confirmed under image intensifier view. Once reduction is achieved, one or two lag screws maintain reduction and create fracture stability. The screws must be placed outside the intramedullary canal, so that they do not hinder nail insertion [26] (Fig. 21.4a–i). As an alternative, K-wires may control reduction, but their holding power is far below the power of lag screws. There will be a higher risk of secondary fracture displacement when stress is put on the fracture fragments during nail insertion. Cerclage wiring is another method for control of fracture reduction. Whereas lag screw fixation is advantageous in oblique metaphyseal fractures, cerclage wiring is useful in fractures with long oblique or spiral diaphyseal extension. Cerclage wires must be inserted minimally invasive and should disturb the periosteal blood supply of the fracture fragments as little as possible [27, 28].

In case adequate fracture reduction is not achieved percutaneously or through small incisions, limited exposure of the fracture gap is an option. Exposure should be done with sharp dissection; removal of intercalated soft tissue elements and manipulation of fracture fragments are performed very carefully to minimize secondary soft tissue damage or compromise blood supply. Reduction is completed with the help of Schanz’ screws, reduction forceps or bone clamps and secured with lag screws, K-wires or a small plate. The plate is put on the bending side, which is the anteromedial aspect of the proximal tibia. The screws must be monocortical to allow free passage of the nail. The implant can optionally remain in place once the nail is inserted [29].

The choice of the correct entry portal is of utmost importance for every nailing procedure. The entry portal of an imaginary straight tibia nail lies in line with the central axis of the endomedullary canal in anteroposterior and lateral view. This entry point is situated inside the knee joint at the intercondylar eminence. Creating this entry portal would damage the distal insertion of the anterior cruciate ligament. For this reason, tibia nails are bent or curved in the sagittal plane and allow for a more anterior entry portal. In proximal fractures, the distance between the tibia plateau and the fracture site is short. Creating adequate stability through multiple interlocking implies an intra-osseous pathway of maximal length for the nail in the short proximal fragment. The entry portal must therefore be as proximal as possible, at the level of the tibia plateau but not inside the knee joint. McConnell et al. identified this so-called “safe zone” [30]. It is situated just medial to the lateral tibial spine in the anteroposterior radiograph and just anterior to the spine in the lateral radiograph (Fig. 21.5). Hernigou and Cohen described the “unrecognized” risk of joint penetration in tibia nailing, especially damaging the anterior horn of the medial or lateral meniscus, the ligamentum transversum and the medial and lateral tibia plateau cartilage [31]. Walker et al. proved the importance of a true anteroposterior radiograph for the finding of the optimal insertion point. When the tibial head was visualized in external rotation, a too medial insertion point was obtained. The ideal radiographic view correlates with a position of the tibial head, in which the fibular head is cut into two equal parts by the lateral tibial cortex, this is with the tibial head between 0 and 10° of internal rotation [32]. A medial entry portal will push the fracture in valgus; a too lateral entry portal will push the fracture into varus, a too anterior entry portal will push the fracture in antecurvation [33] (Fig. 21.6a, b). Althausen et al. recommend taking a preoperative fluoroscopic view and identifying the ideal entry portal before a skin incision is made. Depending on the patellar tendon anatomy in relation to this entry portal, a medial parapatellar, transpatellar or lateral parapatellar approach is chosen. Using the same skin incision for every nailing procedure is not justified [34].

The nail, which is selected for fixation of proximal tibia fractures, should create enough stability to allow early active postoperative knee motion. It therefore must guarantee stable interlocking in different planes in the proximal fragment. Different prerequisites must be fulfilled [35]: the bent of the nail must allow for insertion through the safe zone, interlocking in three different planes must be possible, toggling of the screws in the nail should be minimal or angular stable interlocking created [36]. Hansen et al. proved that triple interlocking of the proximal tibia fragment creates a significantly higher stability in proximal tibia fractures than double interlocking [37]. Interlocking screws should be inserted in the strong subchondral area and may not perforate the opposite cortex to avoid neurologic damage [38]. Hansen et al. calculated the distance between the dorsal cortex of the proximal tibia and the neurovascular structures in the popliteal fossa and showed that limited perforation of the tip of an anteroposteriorly placed interlocking screw does not place these neurovascular structures at risk. In 99 cases, the distance between the posterior tibial cortex and the neurovascular bundle at the level of the knee joint was measured in MRI. The mean distance was 11.5 mm varying between 4 and 21 mm [39]. Spongiosa thread enhances the bone-implant interface and increases the holding power of the screws in the bone.

Nail insertion is carried out after fracture reduction, provisional fracture fixation and creation of the correct entry portal. There still is discussion on the ideal knee flexion for finding the ideal slope for nail insertion. When the knee joint is extended, the patella hinders choosing a flat slope. Avoiding the patella by taking the nail medially or laterally enhances the risk of malalignment due to the oblique corridor of the nail in the proximal fragment. When the knee joint is flexed more than 90°, the patella is fixed in the femoral trochlea and does not disturb a flat slope for nail insertion anymore. But bringing the knee in more than 90° of flexion after fracture reduction and provisional fixation enhances the risk of secondary displacement. Tornetta and Collins perform a medial 2/3 parapatellar approach with lateral subluxation of the patella. The intercondylar groove is used for flat nail insertion. An apex anterior angulation of more than 5° was avoided in 25 consecutive cases [40]. Kubiak et al. present an extra-articular nailing technique in semi-extended position [41]. Recently, a suprapatellar approach for tibia nailing has been described (Fig. 21.7a–i). The patellofemoral contact pressures while inserting the nail measured by Gelbke et al. were found far below the critical values for cartilage damage [42]. Jakma et al. found some scuffing in the distal part of the femoral trochlea, when no specific protection is used [43]. It is therefore recommended that the nail is inserted through a weak and flexible sleeve which has been put in place with the help of a trocar. Eastman et al. proved that the favorable entrance vector is found with knee flexion of more than 20° [44]. A nice overview of tips and tricks for successful nailing of proximal tibia fractures is given by Liporace et al. [45].

Additional aids may be needed to secure correct nail placement. We recommend using cannulated nails only and inserting a guide wire first. In the distal metaphysis, the tip of the guide wire must be placed centrally in the anteroposterior and lateral views. When the location of the entry portal and the tip of the guide wire have been defined correctly, the nail will find its correct position. To avoid secondary displacement of the provisionally reduced fracture, all manipulations must be done very carefully and without major force. Hammering the nail in the intramedullary canal is not recommended. Therefore, it is suggested that the endomedullary canal is carefully reamed to a diameter, which is 0.5 till 1 mm above the diameter of the selected nail. Guiding the nail into its correct corridor is made easier with intramedullary blocking screws. They create an artificial isthmus in the metaphyseal area. In the proximal tibia fragment, the screws are usually inserted near the posterior cortex in the coronal plane to avoid apex anterior angulation or near the lateral cortex in the frontal plane to avoid valgus angulation (see also Chap.​ 6) (Fig. 21.4a–i) [24, 46–49].

After nail insertion, the guide wire is removed and distal interlocking performed first. In isolated proximal fractures, distal locking with two parallel screws from medial to lateral is adequate. In segmental fractures, where the distal fragment is short, triple interlocking is recommended. After distal interlocking, closure of the remaining fracture gap can be achieved with careful reverse blows on the insertion handle. Proximal interlocking finishes the nailing procedure. Three interlocking screws are inserted and angular stability achieved with the insertion of an end cap, which pushes against the proximal screw. Image intensification control of the proximal metaphysis, the fracture area and the distal metaphysis confirms correct placement of the nail and the interlocking screws as well as good alignment of the fracture fragments.

In segmental tibia fractures with a high proximal fracture, nailing of the proximal fracture is the most challenging part of the procedure (Fig. 21.8a–f). All recommendations for nailing of isolated proximal tibia fractures are relevant. Especially, it is recommended to use a guide wire and gentle reaming for easier nail insertion. Once the nail has passed the proximal fracture, gentle rotatory movements or gentle hammer blows will bring the nail down. When the second fracture is situated in the shaft, nail insertion will correct angulation. When the second fracture is situated in the distal third, similar reduction aids and aids for guidance of the nail will be necessary as in proximal third fractures (see also Chap.​ 23). Nailing is also a valid option in segmental fractures with multiple fracture levels, multifragmentary fractures with a short proximal fragment, segmental bone defects and for segmental transport [50].