Summary Proximal third tibia fractures are relatively common fractures of the proximal tibial shaft that are associated with high rates of soft tissue compromise and malunion (valgus and procurvatum). Diagnosis is made with orthogonal radiographs of the tibia with CT scan often required to assess for intra-articular extension. Treatment generally consists of surgical open reduction and internal fixation (ORIF) versus intramedullary nail fixation. Epidemiology Incidence common 5-11% of all tibial shaft fractures Etiology Pathophysiology mechanism low energy result of torsional injury (spiral oblique fracture) indirect trauma high energy direct trauma Associated conditions compartment syndrome soft tissue injury critical to outcome severity of muscle injury has the greatest impact on need for amputation Anatomy Osteology proximal tibia triangular wide metaphyseal region narrow distally Muscles deforming forces patellar tendon proximal fragment into extension fracture into apex anterior, or procurvatum gastrocnemius distal fragment into flexion pes anserinus proximal fragment into varus varus deforming force of the fracture anterior compartment musculature valgus deforming force of the fracture Classification AO Classification - 42 Type A Simple fracture pattern Type B Wedge fracture pattern Type C Comminuted fracture pattern Presentation Symptoms pain, inability to bear weight Physical exam inspection contusions blisters open wounds compartments palpation passive motion of toes intracompartmental pressure measurement if indicated neurovascular deep peroneal n. superficial peroneal n. sural n. tibial n. saphenous n. dorsalis pedis posterior tibial Imaging Radiographs recommended views AP lateral ipsilateral knee, tibia, and ankle findings proximal fracture extended, apex anterior, varus apex extended due to patellar tendon varus due to pes anserinus + anterior compartment distal fragment flexed flexed due to gastrocnemius CT indications question of intra-articular fracture extension Differential Tibial shaft fx Knee dislocation Tibial plateau fx Diagnosis Radiographic diagnosis confirmed by clinical presentation and radiographs Treatment Nonoperative closed reduction / cast immobilization indications closed low energy fractures with acceptable alignment < 5 degrees varus-valgus angulation < 10 degrees anterior/posterior angulation > 50% cortical apposition < 1 cm shortening < 10 degrees rotational alignment outcomes shortening is most difficult to control with nonoperative management angulation and rotational control are difficult to achieve by closed methods extent of shortening and translation on injury radiographs should be expected at time of union Operative external fixation indications fractures with extensive soft-tissue compromise polytrauma outcomes higher incidence of malalignment than IMN intramedullary nailing indications enough proximal bone to accept two locking screws (5-6 cm) outcomes high rates of malunion with improper technique most common malunion valgus apex anterior (procurvatum) percutaneous locking plate indications extreme proximal fractures inadequate proximal fixation for IM nailing best suited for transverse or oblique fractures minimal soft-tissue compromise outcomes lateral plating with medial comminution can lead to varus collapse long plates may place superficial peroneal nerve at risk higher infection rate that IMN for open fractures Techniques Closed reduction / cast immobilizxation technique place in long leg cast and convert to functional brace at 4 weeks cast in 10 to 20 degrees of flexion External fixation technique bi-planar and multiplanar pin fixators are useful circular frames indicated for very proximal fractures can be safely converted to IMN within 7-21 days Intramedullary nailing approach lateral parapatellar helps maintain reduction for proximal 1/3 fractures requires mobile patella medial parapatellar approach may lead to valgus deformity suprapatellar facilitates nailing in semiextended position technique starting point proximal to the anterior edge of the articular margin just medial to the lateral tibial spine use of a more lateral starting point may decrease valgus deformity use of a medial starting point may create valgus deformity fracture reduction techniques blocking (Poller) screws coronal blocking screw prevents apex anterior (procurvatum) deformity place in posterior half of proximal fragment sagittal blocking screw prevents valgus deformity place on lateral concave side of proximal fragment enhance construct stability if not removed unicortical plating short one-third tubular plate placed anteriorly, anteromedially, or posteromedially across fracture secure both proximally and distally with 2 unicortical screws universal distractor Schanz pins inserted from medial side, parallel to joint pin may additionally be used as blocking screws nail insertion options standard insertion with knee in flexion nail insertion in semiextended position may help to prevent apex anterior (procurvatum) deformity neutralizes deforming forces of extensor mechanism locking screws statically lock proximally and distally for rotational stability no indication for dynamic locking acutely must use at least two proximal locking screws complications malunion valgus and apex anterior (procurvatum) Pecutaneous locking plate approach anterolateral straight or hockey stick incision anterolaterally from just proximal to joint line (if intra-articular extenion) to just lateral to the tibial tubercle and extend distally as needed technique may be used medially or laterally better soft tissue coverage laterally makes lateral plating safer complications superficial peroneal nerve injuy with use of a longer plate varus collapse if lateral only plate used with medial comminution Complications Anterior knee pain incidence occurs in more than 30% of cases treated with IMN resolves with removal of IMN in 50% of cases Nonunion infection must be ruled out dynamization if axially stable Malunion Most common is valgus and apex anterior (procurvatum) increases long-term risk of arthrosis incidence 20-60% rate of malunion following intramedullary nailing (valgus/procurvatum) prevention laterally based starting point and anterior insertion angle entry of IMN should be in line with the medial border of the lateral tibial eminence blocking screws placed in metaphyseal segment on the concave side of the deformity place laterally to prevent valgus and posterior to prevent procurvatum in proximal fragment this narrows the available space for the IMN direct the nail toward a more centralized position use of provisional unicortical plate semiextended position for nailing universal distractors treatment revision intramedullary nailing osteotomy if fracture has healed Prognosis High rate of malunion following intramedullary nailing
Technique Guide Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. Tibial Shaft Fx Intramedullary Nailing Team Orthobullets (D) Trauma - Tibial Shaft Fractures
QUESTIONS 1 of 31 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ18.156) A 23-year-old-male was involved in a motorcycle accident. Imaging is shown in Figure A. In order to prevent the most common deformity associated with intramedullary nailing of this injury, where should blocking screws be placed and what deformity are they trying to prevent? QID: 213052 FIGURES: A B Type & Select Correct Answer 1 Lateral and posterior to the nail in the proximal segment; procurvatum and valgus 81% (1836/2263) 2 Medial and posterior to the nail in the proximal segment; procurvatum and varus 7% (159/2263) 3 Lateral and posterior to the nail in the proximal segment; recurvatum and varus 6% (130/2263) 4 Medial and anterior to the nail in the proximal segment; recurvatum and valgus 4% (99/2263) 5 Anterior and posterior to the nail in the proximal segment; recurvatum 1% (13/2263) L 2 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (SBQ16SM.35) A 46-year-old male presents with the radiographs in Figure A following a skiing accident. You decide to treat this injury with an intramedullary nail. During insertion of your nail, it's decided that blocking screws are needed. In which position should they be placed to prevent the most common malunion? QID: 211491 FIGURES: A Type & Select Correct Answer 1 A and D 4% (70/1789) 2 A and C 9% (157/1789) 3 B and C 82% (1468/1789) 4 B and D 5% (83/1789) 5 A and B 0% (5/1789) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ13.149) Figures A through E are paired diagrams depicting the anteroposterior and lateral profiles of the proximal tibia. Which of the following figures has arrows that correspond to the ideal entry point for intramedullary nailing of a proximal third diaphyseal tibial fracture? QID: 4784 FIGURES: A B C D E Type & Select Correct Answer 1 Figure A 15% (753/5025) 2 Figure B 70% (3506/5025) 3 Figure C 10% (508/5025) 4 Figure D 3% (142/5025) 5 Figure E 2% (109/5025) L 3 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic (SBQ12TR.22) A 34-year-old male presents with a closed left leg injury after falling off a 20ft ladder. His injury radiographs are shown in Figure A. He is taken for intramedullary nail (IMN) fixation. Which of the following correctly combines techniques used to decrease the incidence of the most common deformities associated with this fracture pattern? QID: 3937 FIGURES: A B C D E F Type & Select Correct Answer 1 Starting point in Figure B with blocking screw in Figure D 3% (53/1870) 2 Starting point in Figure B with blocking screw in Figure E 11% (209/1870) 3 Starting point in Figure C with blocking screw in Figure D 8% (143/1870) 4 Starting point in Figure C with blocking screw in Figure E 74% (1389/1870) 5 Starting point in Figure C with blocking screw in Figure F 3% (63/1870) L 2 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (SBQ12TR.17) A 34-year-old man is involved in a motorcycle accident and sustains a closed tibia fracture and multiple rib fractures. A radiograph is provided in Figure A. During surgical treatment of this fracture, which of the following techniques will help facilitate a successful reduction and intramedullary fixation? QID: 3932 FIGURES: A Type & Select Correct Answer 1 Hyperflexion to help prevent apex anterior angulation 3% (69/2368) 2 A medial parapatellar incision to help prevent valgus angulation 1% (34/2368) 3 Starting point just lateral to the medial tibial eminence to help prevent valgus angulation 12% (290/2368) 4 A medially placed blocking screw to help prevent valgus angulation 10% (227/2368) 5 Suprapatellar nailing technique to help prevent apex anterior angulation 73% (1725/2368) L 3 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ12.6) 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? QID: 4366 FIGURES: A B Type & Select Correct Answer 1 Insertion of blocking screws lateral and posterior to the nail 64% (3876/6037) 2 Insertion of blocking screws medial and posterior to the nail 14% (821/6037) 3 Insertion of blocking screws lateral and anterior to the nail 10% (607/6037) 4 Insertion of blocking screws medial and anterior to the nail 10% (589/6037) 5 Insertion of blocking screws medial, lateral, and posterior to the nail 1% (80/6037) L 3 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ11.161) 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? QID: 3584 FIGURES: A B Type & Select Correct Answer 1 Nail of a lesser radius of curvature 4% (142/4018) 2 Nail with a more distal Herzog curve 7% (279/4018) 3 Application of an anterior unicortical plate 77% (3079/4018) 4 Nailing while in a hyperflexed position 6% (251/4018) 5 A more distal and medial nail entry site 6% (247/4018) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ11.193) 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? QID: 3616 Type & Select Correct Answer 1 Tibial nailing with increased knee flexion 2% (40/2606) 2 Lateral blocking screw in the proximal fragment 1% (33/2606) 3 Medial blocking screw in the proximal fragment 1% (21/2606) 4 Anterior blocking screw in the proximal fragment 13% (345/2606) 5 Posterior blocking screw in the proximal fragment 83% (2160/2606) L 2 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (OBQ11.264) 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? QID: 3687 Type & Select Correct Answer 1 Semiextended position during nailing 76% (2923/3867) 2 Lateral blocking screws in proximal tibia fragment 4% (141/3867) 3 Use of a radiolucent triangle to flex the knee 5% (185/3867) 4 Anterior blocking screw in the proximal tibia fragment 15% (571/3867) 5 Medial parapatellar arthrotomy avoiding the patellar tendon 1% (27/3867) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (OBQ10.140) Which of the following techniques has not been shown to prevent valgus angulation during intramedullary nailing of proximal one-third tibia fractures? QID: 3228 Type & Select Correct Answer 1 Use of a blocking screw lateral to midline in the proximal segment 12% (348/2826) 2 Use of femoral distractor 44% (1244/2826) 3 Use of a lateral tibial nail starting point 8% (231/2826) 4 Use of supplementary plate and screw fixation 2% (69/2826) 5 Use of a suprapatellar nailing portal 33% (920/2826) L 4 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (OBQ09.176) 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? QID: 2989 FIGURES: A B Type & Select Correct Answer 1 Anterior to the nail in the proximal segment; medial to the nail in the proximal segment 7% (131/1953) 2 Anterior to the nail in the proximal segment; lateral to the nail in the proximal segment 11% (212/1953) 3 Posterior to the nail in the proximal segment; lateral to the nail in the proximal segment 74% (1446/1953) 4 Anterior to the nail in the distal segment; lateral to the nail in the distal segment 3% (50/1953) 5 Posterior to the nail in the distal segment; medial to the nail in the proximal segment 5% (99/1953) L 2 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (OBQ09.189) 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? QID: 3002 FIGURES: A Type & Select Correct Answer 1 Medial starting point 10% (232/2397) 2 Lateral starting point 64% (1530/2397) 3 Aiming the nail posteriorly in the proximal segment 2% (46/2397) 4 Anterior blocking screw in the proximal segment 8% (184/2397) 5 Medial blocking screw in the proximal segment 17% (397/2397) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ06.269) All of the following techniques can help to prevent apex-anterior angulation during intramedullary nailing of proximal one-third tibia fractures EXCEPT: QID: 280 Type & Select Correct Answer 1 Posterior blocking screw in the proximal segment 13% (111/887) 2 Posterior starting hole 4% (36/887) 3 Interlocking the nail in a semi-extended knee position 3% (24/887) 4 Anteriorly directing the nail 5% (42/887) 5 Anterior blocking screw in the proximal segment 75% (666/887) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (OBQ06.201) 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? QID: 212 FIGURES: A B Type & Select Correct Answer 1 Compartment syndrome 14% (125/905) 2 Common peroneal nerve injury 17% (154/905) 3 Superficial peroneal nerve injury 58% (527/905) 4 Deep peroneal nerve injury 10% (91/905) 5 Popliteal artery injury 0% (4/905) L 3 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (OBQ06.275) Which of the following is an advantage of using blocking screws for tibial nailing? QID: 286 Type & Select Correct Answer 1 Decrease risk of nail breakage 15% (207/1423) 2 Eliminate use of interlocking screws 1% (12/1423) 3 Allow for larger nail use 8% (118/1423) 4 Enhance construct stiffness 70% (999/1423) 5 Decrease torsional rigidity 6% (82/1423) L 3 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (OBQ05.255) 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? QID: 1141 FIGURES: A Type & Select Correct Answer 1 Apex anterior and varus 10% (212/2148) 2 Apex anterior and valgus 81% (1750/2148) 3 Apex posterior and varus 1% (32/2148) 4 Apex posterior and valgus 4% (92/2148) 5 Rotational 3% (57/2148) L 2 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic
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