Wedge fracture pattern
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Average 3.8 of 31 Ratings
Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC.
A 75-year-old-male presents after being struck by a vehicle while crossing the street. He complains of right leg pain, and physical exam reveals no evidence of an open fracture. Initial radiographs are shown in Figures A and B, and intramedullary nailing of the fracture is planned. What is the proper blocking screw technique to prevent apex anterior and valgus deformity of the fracture?
Insertion of blocking screws lateral and posterior to the nail
Insertion of blocking screws medial and posterior to the nail
Insertion of blocking screws lateral and anterior to the nail
Insertion of blocking screws medial and anterior to the nail
Insertion of blocking screws medial, lateral, and posterior to the nail
Select Answer to see Preferred Response
Apex anterior and valgus deformity of the proximal tibia fracture can be prevented by inserting blocking screws lateral and posterior to the nail in the proximal segment.
Blocking screws may be used to prevent deformity when performing intramedullary fixation of proximal tibia fractures. Insertion of the blocking screw lateral to the nail prevents valgus deformity, and insertion of the blocking screw posterior to the nail prevents apex anterior deformity. A more lateral starting point for nail insertion can also help to prevent valgus deformity. Stability screws can be placed prior to insertion of the nail to prevent deformity during nail passage, or after nail insertion to prevent post-operative deformity from developing.
Ricci et al. describe the technique and results of using blocking screws and intramedullary nails to treat patients with fractures of the proximal third of the tibial shaft. Post-operatively, all patients in their series had less than 5 degrees of angular deformity in the planes in which blocking screws were used to control alignment. At 6 months follow-up, 10/11 patients maintained this alignment.
Figures A and B demonstrate a segmental tibial shaft fracture. Illustration A shows an intraoperative fluoroscopic image demonstrating insertion of the blocking screws intraoperatively. Illustrations B and C show post-operative radiographs demonstrating placement of the blocking screws and adequate alignment of the proximal segment.
Ricci WM, O'Boyle M, Borrelli J, Bellabarba C, Sanders R.
J Orthop Trauma. 2001 May;15(4):264-70. PMID: 11371791 (Link to Abstract)
Ricci, JOT 2001
Please rate question.
Average 4.0 of 17 Ratings
A 28-year-old female is struck by a motor vehicle while crossing the street and suffers the injury seen in Figure A. What technical adjunct could have prevented the operative complication seen in Figure B?
Nail of a lesser radius of curvature
Nail with a more distal Herzog curve
Application of an anterior unicortical plate
Nailing while in a hyperflexed position
A more distal and medial nail entry site
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.
J Orthop Trauma. 2006 Sep;20(8):523-8. PMID: 16990722 (Link to Abstract)
Nork, JOT 2006
Dunbar RP, Nork SE, Barei DP, Mills WJ.
J Orthop Trauma. 2005 Jul;19(6):412-4. PMID: 16003202 (Link to Abstract)
Dunbar, JOT 2005
Matthews DE, McGuire R, Freeland AE.
Orthopedics. 1997 Jul;20(7):647-8. PMID: 9243676 (Link to Abstract)
Matthews, ORTHO 1997
Average 4.0 of 19 Ratings
A 45-year-old male sustains a proximal third tibia fracture as an isolated injury and elects to undergo operative treatment with intramedullary nailing. Post-operative radiographs show excessive procurvatum deformity. Which of the following operative techniques would have helped to best avoid the procurvatum deformity?
Tibial nailing with increased knee flexion
Lateral blocking screw in the proximal fragment
Medial blocking screw in the proximal fragment
Anterior blocking screw in the proximal fragment
Posterior blocking screw in the proximal fragment
Posterior blocking screws in the proximal tibial segement help to avoid tibial procurvatum deformity and malunion. Proximal third tibia fractures are often times difficult to reduce anatomically due to the tendency for both valgus and flexion deformity at the fracture site. The posterior blocking screw helps to eliminate the tendency for the nail to be too posterior and cause the fracture to flex. Blocking screws should be placed on the concavity of the deformity to minimize the procurvatum and valgus deformities of this fracture pattern.
Krettek et al looked at the importance of using blocking screws during intramedullary nailing of metaphyseal fractures using small diameter nails. They found less procurvatum deformity and malunions associated with using of blocking screws and found no complication with their utilization.
Ricci et al reviewed fractures of the proximal third of the tibial shaft treated with intramedullary nails and blocking screws. Their results supported that blocking screws were effective in maintaining alignment of fractures of the proximal third of the tibial shaft treated by intramedullary nailing.
Hiesterman et al review different reduction techniques to avoid malalignment, including the use of a proper starting point and insertion angle, blocking screws, unicortical plates, and a universal distractor.
Illustration A shows a radiograph utilizing posterior proximal and distal blocking screws to prevent procurvatum deformity.
1- would exacerbate procurvatum deformity.
2- would help avoid valgus deformity.
3- would exacerbate valgus deformity.
4- would exacerbate procurvatum deformity.
Krettek C, Stephan C, Schandelmaier P, Richter M, Pape HC, Miclau T.
J Bone Joint Surg Br. 1999 Nov;81(6):963-8. PMID: 10615966 (Link to Abstract)
Krettek, BJJ 1999
Hiesterman TG, Shafiq BX, Cole PA.
J Am Acad Orthop Surg. 2011 Nov;19(11):690-700. PMID: 22052645 (Link to Abstract)
Hiesterman, JAAOS 2011
Average 4.0 of 11 Ratings
A 34-year-old female sustains a proximal third tibia fracture as an isolated injury and elects to undergo operative treatment with intramedullary nailing. Which of the following operative techniques would help to best avoid a procurvatum deformity of the tibia?
Semiextended position during nailing
Lateral blocking screws in proximal tibia fragment
Use of a radiolucent triangle to flex the knee
Anterior blocking screw in the proximal tibia fragment
Medial parapatellar arthrotomy avoiding the patellar tendon
The semiextended position for intramedullay nailing of proximal tibia shaft fractures has shown to cause less complications of flexion deformity and malunion. Proximal third tibia fractures are often times difficult to reduce anatomically due to the tendency for both valgus and flexion deformity at the fracture site. The semiextended position helps to eliminate the tendency for the fracture to flex, due to the avoidance of excessive knee flexion during the reduction. Illustration A is an example of semiextended positioning for tibial nailing. Illustration B shows radiograph utilizing posterior blocking screws to prevent procurvatum deformity.
Tornetta et al looked at the semiextended intramedullary nailing of proximal tibia fractures. Of the 24 patients nailed using this technique, 19 had no anterior angulation, while only 5 had less than 5 degrees of flexion deformity.
In their study, Kubiak et al also advocate the semiextended position for tibial nailing. They note better control of fracture alignment and stabilization especially in the sagittal plane, and better ability to obtain imaging and maintenance of reduction during nail insertion and locking.
Answer 2 would help to avoid valgus deformity.
Answer 3 would worsen the flexion deformity.
Answer 4 would worsen the flexion deformity and drive the nail posterior in distal segment.
Answer 5 would not affect flexion deformity.
Tornetta P 3rd, Collins E.
Clin Orthop Relat Res. 1996 Jul;(328):185-9. PMID: 8653954 (Link to Abstract)
Tornetta, CORR 1996
Kubiak EN, Widmer BJ, Horwitz DS.
J Orthop Trauma. 2010 Nov;24(11):704-8. PMID: 20881632 (Link to Abstract)
Kubiak, JOT 2010
Average 4.0 of 12 Ratings
Which of the following techniques does not help prevent valgus angulation during intramedullary nailing of proximal one-third tibia fractures?
Use of a blocking screw lateral to midline in the proximal segment
Use of a blocking screw lateral to midline in the distal segment
Use of a lateral tibial nail starting point
Use of supplementary plate and screw fixation
Use of a suprapatellar nailing portal
Proximal tibial shaft fractures treated with intramedullary nails are most commonly malreduced with apex anterior and valgus deformities. Several techniques are available to overcome this malalignment: proximal and lateral nail starting point, usage of a femoral distractor or temporary plating, suprapatellar nailing, and lateral parapatellar approaches. Suprapatellar nailing portals do not affect coronal angulation - they only affect the apex anterior deformity.
A final technical trick is the usage of blocking (Poller) screws - the referenced article by Ricci et al had 100% correction and maintenance of reduction with usage of blocking screws without other adjunct techniques. These should be placed in the lateral aspect of the proximal and distal fragments when needed. Remember, the blocking screws should go in the concavity of the deformity, or where you don't want the nail to go.
The referenced study by Krettek et al is a biomechanical evaluation of blocking screws in a tibial model that showed significantly increased strength when they were utilized.
Illustration A demonstrates proper AP screws placed lateral to the nail (white large arrows) to prevent valgus deformation, and ML screws placed posterior to the nail (white small arrows) to prevent procurvatum.
Krettek C, Miclau T, Schandelmaier P, Stephan C, Möhlmann U, Tscherne H.
J Orthop Trauma. 1999 Nov;13(8):550-3. PMID: 10714781 (Link to Abstract)
Krettek, JOT 1999
Average 3.0 of 42 Ratings
A 38-year-old male sustains the closed injury shown in Figures A and B. When treating this injury with an intramedullary nail, addition of blocking screws into which of the following positions can prevent the characteristic malunion deformity?
Anterior to the nail in the proximal segment; medial to the nail in the proximal segment
Anterior to the nail in the proximal segment; lateral to the nail in the proximal segment
Posterior to the nail in the proximal segment; lateral to the nail in the proximal segment
Anterior to the nail in the distal segment; lateral to the nail in the distal segment
Posterior to the nail in the distal segment; medial to the nail in the proximal segment
Figures A and B show a proximal tibia fracture, which is prone to malreduction/malunion into a characteristic valgus and procurvatum (apex anterior) deformity. Placement of screws in this instance posterior to the nail (medial to lateral) and lateral to the nail (anterior to posterior) in the proximal segment will prevent iatrogenic malalignment.
Intramedullary nails will not effect a reduction in metaphyseal proximal tibia fractures. Valgus and apex anterior deformities in these injuries may be caused by deforming muscular forces, limb positioning in hyper flexion, as well as iatrogenic deformity created by improper nail insertion technique. Blocking (Poller) screws are utilized to redirect intramedullary nails by creating an artificial cortex to guide the nail into appropriate position.
The referenced biomechanical study by Krettek et al noted that addition of blocking screws added increased stability to metaphyseal fractures.
Ricci et al noted no malalignment intraoperatively or at final follow-up of proximal tibia fractures treated with intramedullary nails if blocking screws were used.
Average 4.0 of 26 Ratings
A 37-year-old male sustains the closed injury seen in figure A. What technique can be utilized to avoid the characteristic deformity seen in this fracture pattern if an intramedullary nail is used for treatment?
Medial starting point
Lateral starting point
Aiming the nail posteriorly in the proximal segment
Anterior blocking screw in the proximal segment
Medial blocking screw in the proximal segment
Figure A shows a proximal metaphyseal tibia fracture, which characteristically is malreduced into valgus and apex anterior (procurvatum) deformity. Some techniques to avoid these deformities are: provisional reduction with unicortical plates/clamps, semi-extended nailing, suprapatellar nailing, usage of a more lateral starting point, usage of an external fixator or femoral distractor, and usage of blocking screws - posterior screw and/or a lateral screw in the proximal segment.
The two referenced studies draw attention to the high rate of malalignment with nailing of this fracture pattern; the first study reported a 58% malalignment rate, and the second reported an 84% rate (>5 degrees in either coronal or sagittal planes).
Freedman EL, Johnson EE.
Clin Orthop Relat Res. 1995 Jun;(315):25-33. PMID: 7634677 (Link to Abstract)
Freedman, CORR 1995
Lang GJ, Cohen BE, Bosse MJ, Kellam JF.
Clin Orthop Relat Res. 1995 Jun;(315):64-74. PMID: 7634688 (Link to Abstract)
Lang, CORR 1995
Average 4.0 of 23 Ratings
A 25-year-old man sustains a left leg injury during a motorcycle accident. A radiograph is provided in Figure A. The fracture is treated in a minimally invasive manner with a lateral locking plate and percutaneous screw fixation. A post-operative radiograph is provided in Figure B. Which of the following complications has been associated with this fixation construct?
Common peroneal nerve injury
Superficial peroneal nerve injury
Deep peroneal nerve injury
Popliteal artery injury
Figures A and B demonstrate pre and post-operative radiographs of a comminuted proximal tibia fracture treated with a long locking plate. Compartment syndrome is a significant complication associated with this fracture. However, there is no greater risk of compartment syndrome with use of this specific construct plate. Long lateral locking plates have been shown to put the superficial peroneal nerve at risk with insertion of distal locking screws. Use of a larger incision and careful dissection down to the plate in this region may minimize the risk of damage to the nerve.
Deangelis et al performed a cadaveric study evaluating 14 extremities and the relationship between the superficial peroneal nerve to the percutaneous screws of the 13-hole proximal tibia Less Invasive Stabilization System (LISS) plate. The average distance from the superficial peroneal nerve to the center of holes 11, 12, and 13 was 10.0 mm, 6.8 mm, and 2.7 mm, respectively. In 12 of 14 legs (86%), the superficial peroneal nerve was 5.0 mm or less from the center of hole 13.
Cole et al reviewed his experience of 77 proximal tibia fractures treated with the LISS plate. He reported a high rate of union (97%) with only 2 infections, 2 nonunions, 1 nerve palsy, and 8 patients with an angular malunion approaching 10 degrees.
Cole PA, Zlowodzki M, Kregor PJ.
J Orthop Trauma. 2004 Sep;18(8):528-35. PMID: 15475848 (Link to Abstract)
Cole, JOT 2004
Deangelis JP, Deangelis NA, Anderson R
J Orthop Trauma. 2004 Sep;18(8):536-9. PMID: 15475849 (Link to Abstract)
Deangelis, JOT 2004
Average 2.0 of 26 Ratings
All of the following techniques can help to prevent apex-anterior angulation during intramedullary nailing of proximal one-third tibia fractures EXCEPT:
Posterior blocking screw
Posterior starting hole
Interlocking the nail in a semi-extended knee position
Anteriorly directing the nail
Anterior blocking screw
Sagittal malalignment is commonly seen after nailing proximal tibia fractures. The start point as well as the direction of the nail can lead to sagittal deformity. Freedman found in nailing tibia fractures that malalignment was seen in 58% of proximal third fractures, 7% of middle third fractures, and 8% of distal third fractures. Of the malaligned fractures, 83% were either segmental or comminuted.
Lang found that a medialized nail entry point and a posteriorly and laterally directed nail insertion angle contributed to malalignment. It is logical that a fracture that is reamed and then nailed in the posterior direction will lead to a gap anteriorly, and that posterior comminution will lead to anterior angulation as the fracture hinges on the intact cortex anteriorly. An anterior starting hole will tend to lead to more of a posterior nail direction.
Tornetta found that using only 15 degrees knee flexion (semi extended) eliminated the extension force of the quadriceps on the proximal fragment, which otherwise would have tended to cause anterior angulation at the fracture site; therefore interlocking in flexion leads to anterior angulation.
Krettek found that a posteriorly placed blocking screw is meant to prevent posterior placement of the nail and therefore encourages decreased anterior angulation of the fracture.
Henley found that if the fracture is high and the nail bend is within the distal fracture fragment, as the nail is inserted, the nail will drive the distal fragment posteriorly.
Henley MB, Meier M, Tencer AF.
J Orthop Trauma. 1993;7(4):311-9. PMID: 8377039 (Link to Abstract)
Henley, JOT 1993
Average 3.0 of 22 Ratings
Which of the following is an advantage of using blocking screws for tibial nailing?
Decrease risk of nail breakage
Eliminate use of interlocking screws
Allow for larger nail use
Enhance construct stiffness
Decrease torsional rigidity
Blocking screws can be used to help obtain and maintain reductions, increase construct stiffness, and neutralize translational forces. There are no studies as of yet that find a blocking screw to decrease nail failure.
Krettek found that medial and lateral blocking screws can increase the primary stability of distal and proximal metaphyseal fractures after nailing and can be an effective tool for selected cases that exhibit malalignment and/or instability by decreasing mechanically measured deformation.
In a later clinical study, Krettek found that after using blocking screws, tibial healing was evident radiologically at a mean of 5.4 months with a decreased rate of malunions.
Ricci also found that blocking screws are effective to help obtain and maintain alignment of fractures of the proximal third of the tibial shaft treated with intramedullary nails.
Average 2.0 of 34 Ratings
A 22-year-old female is struck by a truck and sustains the injury seen in figure A. What deformities are most commonly seen in treating this injury with an intramedullary nail?
Apex anterior and varus
Apex anterior and valgus
Apex posterior and varus
Apex posterior and valgus
Proximal tibial shaft fractures treated with intramedullary nails are most commonly malreduced with apex anterior and valgus deformities. Several techniques are available to overcome this malalignment: proximal and lateral nail starting point, usage of a femoral distractor or temporary plating, suprapatellar nailing, and lateral parapatellar approaches.
A final technical trick is the usage of blocking (Poller) screws - the referenced article by Ricci et al had 100% correction and maintenance of reduction with usage of blocking screws without other adjunct techniques. They report a union rate of >90% in this small series.
Average 3.0 of 21 Ratings
Title: Proximal Tibial Fractures: Nail vs. Plate Presenter: Donald Wiss, MDColum...
HPI - History of fall while playing 2 days back
How would you treat this patient?
HPI - Patient sustained firearm injury from a very close range to his knee
How would you definitely treat this fracture?
HPI - Past history not specific.probably patient developed osteomyelitis about 13 yes back for which incision and drainage was done,subsequently she developed pathological fracture after that.she has been walking with the same for past 13 years
HPI - DM type 1 , 24 hrs prior to admission front seat passenger , RTA , abdominal , pelvic , rt femur and lt tibia pain and tenderness and swelling
How would you treat this patient's femur fracture?
HPI - Fall from standing height 24hours ago
How would you classify this fracture?
HPI - Patient sustained a proximal tibia fracture 4 months prior to presentation. The patient underwent ORIF without any apparent complications.