The patient has a proximal tibia fracture that has been malreduced in procurvatum with anterior translation of the proximal fragment as seen in Figures A and B. Intramedullary nailing of proximal tibia fractures may result in malalignment such as valgus, procurvatum and anterior translation of the proximal fragment.Techniques such as anterior unicortical plating have been described to maintain reduction while placing a locked intramedullary implant.
Nork et al retrospectively review their results using several different intraoperative adjuncts to maintain reduction while nailing proximal tibia fractures including anterior unicortical plates and femoral distractors. They report that, despite high rates of segmental comminution (59.5%) and open fractures (35.1%), acceptable alignment and primary union were achieved in more than 90% of patients.
Dunbar et al describe their technique for application of a provisional unicortical plate through the traumatic wound to maintain reduction during intramedullary nailing of Gustilo-Anderson Type III open tibia fractures. The authors advocate that further soft tissue stripping during plate placement should be avoided, and found excellent results in terms of coronal and sagittal plane alignment for fractures treated with this technique.
Matthews et al review their experience with unicortical plating to maintain reduction during intramedullary nailing of tibia fractures. Similar to the other referenced studies, the authors found the technique assisted with maintaining reduction intraoperatively.
Illustrations A and B demonstrate maintenance of reduction of a proximal tibia fracture using an anterior unicortical plate as a reduction tool during intramedullary nailing.
Answer 1: Nail of a lesser radius of curvature. Unlike femoral nails, tibial nails are straight to match the coronal/sagittal axis of the tibia and therefore a nail with a lesser radius of curvature (more bend) would not match the anatomy and likely lead to malalignment
Answer 2: Nail with a more distal Herzog curve. The proximal bend for tibial IM nails, known as the Herzog curve, may cause malalignment in proximal tibia fractures due to a phenomenon known as the "wedge effect". Nails with more distal Herzog curves have been implicated in anterior translation of the proximal fragment.
Answer 4: Nailing in a hyperflexed position would cause extension of the proximal fragment due to tension on the extensor mechanism
Answer 5: A more distal and medial entry site would likely lead to further deformity and possible nail cut out through the anterior cortex. A more proximal and lateral entry site is preferred for nailing proximal tibia fractures
Nork SE, Barei DP, Schildhauer TA, Agel J, Holt SK, Schrick JL, Sangeorzan BJ. Intramedullary nailing of proximal quarter tibial fractures. J Orthop Trauma. 2006 Sep;20(8):523-8
PMID:16990722 (Link to Abstract)
Dunbar RP, Nork SE, Barei DP, Mills WJ. Provisional plating of Type III open tibia fractures prior to intramedullary nailing. J Orthop Trauma. 2005 Jul;19(6):412-4
PMID:16003202 (Link to Abstract)
Matthews DE, McGuire R, Freeland AE. Anterior unicortical buttress plating in conjunction with an unreamed interlocking intramedullary nail for treatment of very proximal tibial diaphyseal fractures. Orthopedics. 1997 Jul;20(7):647-8.
PMID:9243676 (Link to Abstract)