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Anterior to the nail in the proximal fragment
7%
93/1323
Posterior to the nail in the proximal fragment
90%
1197/1323
Through the nail in the distal fragment
1%
9/1323
Anterior to the nail in the distal fragment
10/1323
Lateral to the nail in the distal fragment
0%
6/1323
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Placement of a posterior blocking screw in the proximal fragment can counter the deforming force of the patellar tendon, which pulls the proximal fragment in extension. Proximal third tibial shaft fractures are the result of high-energy injuries. Treatment with intramedullary nail constructs offers load-sharing across the fracture and enables immediate weightbearing. However, these fractures often fall into valgus and procurvatum due to the metaphyseal location of the fracture and the deforming forces of the patellar tendon, hamstrings, gastrocnemius, and anterolateral compartment muscles. Placement of a blocking screw posterior to the nail in the proximal fragment counteracts the patellar tendon and gastrocnemius deforming forces. Blocking screw placed lateral to the nail in the proximal fragment counteract the deforming force of the hamstrings (pes anserinus) and the anterolateral compartment muscles. Hiesterman, et al. reviewed intramedullary nailing (IMN) of extra-articular proximal tibia fractures. They reported newer techniques such as blocking screws, provisional plating, semi-extended nailing, and nails with greater interlocking screws have significantly reduced the incidence of malreduction of proximal tibial shaft fractures. They stated the correlation of tibial shaft malalignment and adjacent joint arthritis is unclear. Ricci, et al. performed a prospective study of twelve patients treated with IMN and blocking screws for proximal third tibial shaft fractures. They reported all patients treated with IMN and blocking screws healed with <5 degrees of valgus deformity, whereas those without blocking screws healed in >6 degrees of valgus. They concluded blocking screws are effective at maintaining alignment of proximal third tibial shaft fractures treated with IMN. Figures A and B are the AP and lateral radiographs of the right tibia and fibula with a proximal third tibial shaft fracture.Answers 1, 3, 4, and 5: Placement of a posterior blocking screw in the proximal fragment while countering the deforming force of the patellar tendon.
5.0
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