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Tibial Shaft Fx Intramedullary Nailing

Planning

B

Preoperative Plan

1

Template fracture reduction

  • draw key fragments of fracture and plan the forces required to obtain the reduction

2

Template instrumentation

  • measure diameter of the intramedullary canal and approximate length

3

Execute surgical walkthrough

  • describe key steps of the procedure to the attending verbally prior to the start of the case
  • describe potential complications and the steps to avoid them
C

Room Preparation

1

Surgical instrumentation

  • make sure tibia intramedullary nailing system is present before the start of the case

2

Room setup and equipment

  • radiolucent OR table
  • optional
  • large sharp periarticular clamps or Weber-style clamps
  • large external fixation system or femoral distractor
  • c-arm fluoroscopy
  • c-arm from contralateral side, perpendicular to bed

3

Patient positioning

  • patient supine with feet at the end of the bed, small bump under ipsilateral thigh
  • need to move all lights away from area directly over OR table as this will get in the way of guidewires and reamers
  • step stool to get better angle for reaming
  • prep and drape with full access to foot and ankle to judge intraoperative length, rotation, and alignment

Technique

D

Parapatellar Knee Approach

1

Plan out anterior approach to knee

  • options include
  • medial parapatellar (most common, described below)
  • lateral parapatellar
  • patellar tendon splitting
  • suprapatellar approach
  • in cases of decreased knee flexion, can also use suprapatellar approach through superolateral aspect of patella
  • incision and approach are made ~4cm proximal to the superior edge of the patella

2

Position leg on triangle and make incision

  • flex knee over radiolucent triangle
  • mark out inferior pole of patella, borders of patellar tendon, joint line, tibial tubercle
  • make incision from inferior pole of patella distally 2.5cm towards tibial tubercle along medial 1/3 of patellar tendon

3

Spread down to dissect paratenon

  • identify medial edge of patellar tendon and incise
  • retract patellar tendon laterally
  • insert self-retaining retractor
  • use a Gelpi to maintain access
E

Starting Point and Guidewire Insertion

1

Identify guidewire starting point

  • just medial to the lateral tibial spine on the AP radiograph
  • on anterior cortical downslope on lateral view

2

Open canal with starting point reamer

  • use cannulated starting point reamer to open canal (drill to metaphyseal bone)

3

Insert guidepin

  • guidepin should be placed parallel with canal on AP view and just posterior to parallel on lateral view

4

Advance guidewire proximal to fracture site

  • place balltip guidewire in canal with T-handle
  • place gentle bend at tip of wire
F

Fracture Reduction and Reaming

1

Fracture reduction

  • traction technique
  • reduce fracture by pulling traction over triangle
  • can use small blue towel bump behind leg as a bump
  • use mallet to hold pressure over fracture site
  • can use intramedullary finger reduction tool and/or pointed reduction clamps through skin incisions
  • traveling box technique
  • If working alone or with untrained assistant, or if reduction assistance is needed, apply traveling “box” traction before knee incision
  • can use femoral distractor over pins as an alternate to external fixator bars
  • insert pins through posterior distal tibia (or calcaneous) and posterior proximal tibia (just anterior to fibular head but in posterior proximal tibia)

2

Advance guidewire

  • once fracture reduced, manually push guidewire past fracture site to distal physeal scar

3

Check biplanar imaging to ensure wire is in canal

4

Measure nail length with ruler

  • make sure guidewire is seated at physeal scar

5

Start with size 9mm reamer, then ream up 0.5-1.0mm with each reamer

  • push down through starting hole into bone before starting reamer
  • this prevents eccentric reaming of your starting point
  • can use step stool to get better body position for reaming if needed
  • check chatter from reamer feedback and diaphyseal fit on C-arm imaging
  • minimal to no reaming at fracture site to minimize eccentric reaming
  • ream 1.0mm above size of final nail (i.e. size 12mm reamer head for size 11mm nail)
  • If a distal fracture, don't ream the distal tibia unless the guidewire is in perfect position
G

Nail Insertion with Alignment Techniques (blocking screws)

1

Obtain proper alignment

  • blocking screw technique
  • when coronal or sagittal malalignment is noted, blocking screws are placed on the concavity of the deformity
  • place posterior or lateral to the guide wire in the proximal segment in proximal 1/3 fractures
  • these screws serve as a pseudo-cortex to guide the nail and increase stiffness of the construct

2

Assemble nail

  • build nail on backtable and make sure targeting guide lines up with holes in nail

3

Manually advance nail

  • insert nail over guidewire and push into place manually as much as possible
  • advance to fracture site and minimize mallet use at fracture site to minimize iatrogenic comminution
  • insert nail fully and check lateral C-arm view at the knee to ensure the nail is sunk at or below the edge of the bone

4

Check alignment and rotation

  • check that rotation of the nail is aligned with 2nd metatarsal
  • if compression is needed across fracture site, insert distal interlocking screws via perfect circles technique then backslap distal fragment into proximal fragment
  • must sink nail into proximal segment enough to allow backslapping

5

Remove guidewire

H

Proximal Interlocking Screws

1

Place trochar onto bone

  • attach proximal targeting guide and mark skin with triple sleeves for 2-3 static holes
  • use a 15 blade through skin, spread down to bone with hemostat, place trochar of sleeve on bone

2

Place interlocking screw

  • remove inner sleeve then drill through 1st cortex
  • when hitting 2nd cortex, stop and measure, call out length, then finish 2nd cortex (2nd cortex adds 2-5mm)
  • remove inner sleeve and insert screw
  • be careful not to over tighten screws as they can sink into bone easily in metaphyseal bone

3

Repeat process above for placement of other interlocking screws if indicated

  • can lock screws proximally into nail if the instrumentation allows

4

Remove targeting guide and jig from nail

I

Distal Interlocking Screws

1

Obtain perfect circles

  • bring the knee into full extension and lay entire leg on sterile bumps
  • move to distal tibia and get perfect circles of interlock screws
  • ensure no rotation of the distal tibia is done while getting the fluoroscopic views (move the C-arm, not the leg)
  • magnification of fluoro (x2) can be used if desired, but is not necessary

2

Drill holes for interlocking screws

  • use a 15 blade scalpel to locate the nailhole on medial distal tibia, and incise through skin
  • spread down to bone with hemostat
  • place drill in hole, then center drill parallel to xray beam
  • drill toward center of C-arm beam
  • do not stop drill when bit at nail unless progress halted by eccentric drilling
  • if drilling is off, take drill off bit and leave bit in drilled hole
  • recenter the bit on fluoroscopy and use a mallet to drive it across the nail holes
  • this force may cause malalignment in distal fractures

3

Place interlocking screws

  • measure the depth with a depth gauge or with calibrated drill bit
  • remove drill quickly and insert screw
  • repeat above process for 2nd distal interlocking screw
  • have more freedom to move the limb for fluoroscopy after first screw placed

4

Obtain biplanar fluroscopic images of the proximal, middle, and distal tibia

5

Check limb length, rotation, alignment, and perform a knee ligamentous examination

J

Wound Closure

1

Irrigation, hemostasis, and drain

  • strongly flush out reamings from knee with saline bulb irrigation
  • irrigate until backflow is clear
  • cauterize peripheral bleeding vessels

2

Tissue Closure

  • patellar tendon splitting
  • close patellar tendon and paratenon layers with 0-Vicryl
  • subcutaneous layered closure with 3-0 Vicryl
  • skin closure with staples or suture
  • medial parapatellar
  • close parapatellar arthrotomy, subcutaneous and skin closure

3

Dressings

  • soft incision dressings over knee and distal tibia
  • ACE wrap from distal thigh to toes to help with edema

Patient Care

K

Preoperative History and Physical

1

Obtain history and perform basic physical exam

  • assess lower extremity compartments
  • document distal neurovascular status

2

Order basic imaging studies

  • need biplanar radiographs of entire tibia/fibula, knee, and ankle

3

Perform operative consent

  • describe complications of surgery including
  • post-operative knee pain
  • symptomatic prominent interlocking screws
  • malunion
  • nonunion
  • malrotation
  • compartment syndrome
  • superficial/deep infection
L

Perioperative Inpatient Management

1

Write comprehensive admission orders

  • serial compartment checks x 24 hours
  • advance diet as tolerated
  • pain control
  • wound management
  • remove dressings POD2
  • foley out when ambulating
  • check appropriate labs
  • antibiotics
  • prescribe DVT prophyhlaxis

2

Check radiographs in postop

  • check placement of hardware

3

Initiate Physical Therapy POD 1

  • weight-bearing as tolerated
  • immediate range of motion exercises to knee

4

Appropriate medical management and medical consultation

5

Discharges patient appropriately

  • pain meds
  • outpatient PT
  • schedule follow-up in 2 weeks
  • wound care
M

Outpatient Evaluation and Management

1

Obtains focused history and performs focused exam

  • need to check wounds for evidence of open fracture
  • assess lower extremity compartments
  • document distal neurovascular status
  • check for associated orthopedic injuries

2

Interpret basic imaging studies

  • interpret biplanar radiographs of entire tibia/fibula, knee, and ankle
  • obtain CT scan with
  • distal 1/3 fractures (high rate of posterior malleolar fractures)
  • proximal third fractures (joint line extension)

3

Prescribe and manage nonoperative treatment

  • acceptable alignment for closed tibia fractures
  • <5° varus/valgus, <10° anterior/posterior, >50% cortical apposition, <1cm shortening, <10° rotation
  • can be placed into long leg cast and then a functional brace at 4 weeks

4

Makes informed decision to proceed with operative treatment

  • describes accepted indications and contraindications for surgical intervention

5

Provides post-operative management and rehabilitation

  • postop: 2-3 week postoperative visit
  • wound check
  • staples/sutures removed
  • continue physical therapy and range of motion exercises repeat radiographs of tibia
  • diagnose and management of early complications
  • repeat xrays of tibia
  • postop: ~ 3 month postoperative visit
  • diagnosis and management of late complications
  • repeat xrays of tibia
  • postop: 1 year postoperative visit
  • repeat xrays of tibia
N

Advanced Evaluation and Management

1

Prioritizes the needs of the polytrauma patient

  • timing of long bone fixation
  • works with consulting

2

Order and interpret advanced imaging studies

3

Complex wound management and debridement

  • understanding need for consultation for flap coverage

4

Capable of treating complications both intraoperatively and post-operatively

  • manages post operative infection
O

Complex Patient Care

1

Develops unique, complex post-operative management plans

 

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