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Intramedullary Nailing of Proximal Third Tibial Fractures: Techniques to Improve Reduction

Article  in  Orthopedics · July 2011

DOI: 10.3928/01477447-20110526-19 · Source: PubMed

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 ■ trauma update
Section Editors: David J. Hak, MD, MBA & Philip F. Stahel, MD

Intramedullary Nailing of Proximal Third Tibial

Fractures: Techniques to Improve Reduction
David J. Hak, MD, MBA

Abstract: Obtaining and maintaining an acceptable reduction

of proximal third tibial fractures can be problematic. Deform-
ing forces acting on the proximal fragment and the spacious-
ness of the intramedullary canal at this level contribute to this
challenge during intramedullary nailing. Several surgical tech-
niques have been developed to address this problem, including
the use of a more lateral and proximal starting point, adjunc-
tive plate fixation, blocking screws, semiextended nailing, and
most recently the use of a retropatellar portal approach. Famil-
iarity with these techniques is critical to achieve satisfactory
results when nailing proximal third tibial fractures.

I ntramedullary nailing of
simple diaphyseal tibial
shaft fractures usually results
maintain accurate reduction,
extra-articular proximal third
tibial fractures treated with an
in near anatomic reduction, intramedullary nail will com- 1 2
as the intramedullary nail fills monly be malreduced in val- Figure 1: Malreduction following intramedullary nailing of a proximal third
the intramedullary canal. In gus, apex anterior, and have tibial fracture. Figure 2: The distal location of the Herzog bend of this older
unreamed Synthes tibial nail caused posterior and distal displacement of the
contrast, accurate reduction of posterior displacement of the shaft segment during nail insertion.
tibial fractures that are near the distal segment.
proximal metaphyseal junction Two studies published in
are notoriously problematic 1995 highlighted the difficulty fractures of the proximal third Johnson2 reported malalign-
when treated by intramedul- of achieving an adequate re- of the tibia treated with an in- ment (defined as a ⭓5⬚ angu-
lary nailing (Figure 1). duction when nailing proximal tramedullary nail. At follow- latory deformity in any plane)
In the absence of special tibial fractures. Lang et al1 re- up, 84% of their patients had in 7 of 12 (58%) proximal third
techniques to achieve and ported on 32 extra-articular angulation ⬎5⬚ in the frontal or tibial fractures treated with an
sagittal plane, and 59% had ⭓1 intramedullary nail.
Dr Hak is from Denver Health/University of Colorado, Denver, Colorado. cm displacement at the fracture At that time, the design of
Dr Hak has no relevant financial relationships to disclose. site. They noted that valgus, 1 of the most commonly used
Correspondence should be addressed to: David J. Hak, MD, MBA, Den-
apex anterior, and residual dis- intramedullary nail had a dis-
ver Health/University of Colorado, 777 Bannock St, MC 0188, Denver, CO
80204 (david.hak@dhha.org). placement at the fracture site tal Herzog bend (Figure 2).
doi: 10.3928/01477447-20110526-19 were common. Freedman and Henley et al3 outlined how a

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 ■ trauma update

3 4A 4B 5A 5B
Figure 3: Apex anterior angulation is commonly seen in proximal tibial fractures treated with an intramedullary nail. This deformity occurs when the knee is flexed
to obtain the entry site. Attachment of the patellar tendon to the proximal fracture segment results in apex anterior malalignment as the knee is flexed. Figure 4:
On the AP view, the ideal entry site for a proximal tibial fracture nailing should be aligned with the lateral tibial eminence (A). On the lateral view, the ideal entry
site should be more proximal (B). Figure 5: Lateral radiograph of a segmental tibial fracture (A). A 7-hole compression plate has been placed anterior to the path
of the intramedullary nailing for reduction of the proximal portion of this segmental tibial fracture (B).

nail with a Herzog bend distal
to the fracture site becomes
wedged, displacing the distal
segment posteriorly and dis-
tally as it is inserted. Since
that time, contemporary intra-
medullary nails have been de-
signed that have a more proxi-
mal Herzog bend with greater
proximal interlocking options.
Despite these improvements,
difficulties remain in achiev-
ing a satisfactory reduction
when nailing proximal tibial
fractures.
Two main factors compli-
cate the reduction of extra-
articular proximal tibial frac-
tures: (1) the deforming forces
acting on the proximal tibial
segment; and (2) the spacious-
ness of the intramedullary ca-
nal at this level.
Flexion of the knee is re-
quired to create a traditional
intramedullary nail entry site in
the proximal tibia. Because of
the attachment of the patellar
tendon to the proximal fracture
segment, apex anterior dis-
placement occurs (Figure 3).
In response to these prob-
lems, surgeons have developed
several techniques to achieve
an improved reduction when
nailing proximal third tibial
fractures, including: (1) start-
ing point location; (2) ad-
junctive plating; (3) blocking
screws; (4) semiextended nail-
ing technique; and (5) retropa-
tellar portal technique.
STARTING POINT LOCATION
Buehler et al4 reported
on the use of a more lateral
and proximal entrance site to
achieve reduction of proximal
tibial shaft fractures. They also
used a medially placed univer-
sal distractor and placed the in-
terlocking screws with the knee
in full extension using a special
proximal interlocking jig.
A more lateral and proxi-
mal entry site is helpful to
avoid malreduction in proxi-
mal tibial fractures (Figure 4).
Proximally, the medial side of
the tibia has been described as
a chute that deflects the nail
laterally.4 The central axis of
the intramedullary canal is
most commonly aligned with
the lateral tibial eminence. Us-
ing a more proximal entry site
will achieve a longer segment
of nail within the proximal
segment and usually place the
nail’s Herzog bend completely
within the proximal segment,
rather than at or distal to the
fracture site.
ADJUNCTIVE PLATING
Several surgeons have pro-
posed temporary or permanent
placement of a small fragment
plate to maintain reduction of
the proximal fracture and al-
low the knee flexion required
to insert an intramedullary
nail.5-7 Clinically, both one-
third tubular and small-frag-
ment compression plates have
been used. Locking plates
provide another useful option.
A 4- to 6-hole plate is com-
monly used. The plate can be
used temporarily and removed
after the nail is successfully in-
serted and interlocked, or left
in place to assist with maintain-
ing the reduction. With the use
of unicortical screws, the plate
can be positioned along almost
any surface. Good screw pur-
chase can usually be obtained
with a plate placed anteriorly
in the area of thick cortical
bone. Alternatively, the plate
can be placed along the medial
surface. In this case, bicortical
screws may be placed from me-
dial to lateral as long as they are
anterior to the proximal path of
the nail (Figure 5).
Nork et al,7 in a series of 37
fractures of the proximal quar-
ter of the tibia, discussed the
use of supplemental unicortical
plates for 13 of the fractures.
In 3 cases, the plates were used
temporarily as a reduction aid
and removed, while in the
other 10 cases they were left in

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6A 6B 7 8
Figure 6: Valgus deformity is seen during initial insertion of an intramedullary nail of the proximal portion of this segmental fracture (A). The nail was removed
and a blocking screw (arrow) placed just lateral to the central axis of the tibia to correct this deformity (B). Figure 7: To correct apex anterior angulation, a block-
ing screw should be placed just posterior to the intended ideal nail pathway, as shown in this lateral diagram. As the nail passes anterior to the blocking screw,
reduction is achieved. Figure 8: To correct valgus deformity, a blocking screw is placed just lateral to the central axis of the tibia, as shown in this AP diagram.
As the nail is passed medial to the blocking screw, reduction is achieved.

place. They placed plates both
anteriorly and posteromedially
with screws directed to avoid
interference with the reamers
and the intramedullary nail.
They reported that the plates
were effective in maintaining
the reduction and did not ad-
versely affect the healing of
the fracture.
BLOCKING SCREWS
Krettek et al8 described
the use of Poller or blocking
screws to improve reduction in
metaphyseal fractures treated
with intramedullary nailing.
The blocking screws essen-
tially reduce the size of the
available nail pathway. Prop-
erly positioned screws can
prevent malreduction as a nail
is placed into a large metaphy-
seal space.
Ricci et al9 reported on the
use of blocking screws in 12
patients with proximal third
tibial fractures treated with
intramedullary nailing. They
found that the blocking screws
were effective in obtaining and
maintaining alignment of the
fractures.
Proper placement of block-
ing screws can be difficult. If
they are placed too close to
the intended ideal nail path-
way, the nail may not be able
to be passed, while if they are
placed too far from the intend-
ed ideal nail pathway, they will
not adequately aid reduction of
the fracture. Blocking screws
can be placed preemptively
to prevent known deformity.
Alternatively, if a malreduc-
tion occurs during placement
of an intramedullary nail,
the nail can be extracted, the
blocking screw(s) placed, and
the nail reinserted (Figure 6).
Intraoperative fluoroscopy is
routinely used to assess the
optimal position for placement
of a blocking screw.
To prevent apex anterior
deformity, a blocking screw is
placed from medial to lateral
just posterior to the intended
ideal posterior location of the
intramedullary nail (Figure 7).
To prevent valgus angula-
tion, a blocking screw should
be placed just lateral to the
central axis of the tibia (Figure
8). As the nail is passed medial
to the locking screw, the defor-
mity is corrected. In contrast,
to prevent varus angulation,
which is less commonly seen
in proximal tibial fractures,
a blocking screw should be
placed just medial to the cen-
tral axis of the tibia.
SEMIEXTENDED NAILING
TECHNIQUE
Tornetta and Collins10 pro-
posed using an extended in-
cision, releasing the medial
patellar retinaculum to allow
subluxation the patella later-
ally to permit entry site cre-
ation and intramedullary nail
insertion with the knee in only
15⬚ of flexion. By moving the
patella out of the way, the en-
try site can be obtained with
the knee in near full extension,
with the awl or opening drill
flush up against the trochlear
groove of the femur (Figure
9).
RETROPATELLAR PORTAL
TECHNIQUE
Most recently, a retropatel-
lar portal technique has been
developed for tibial nail inser-
tion (Figure 10). It provides
the knee extension benefit
of the semiextended nailing
technique without the need
for an extensile incision. In
this approach, a suprapatellar
incision is used and the quad-
riceps tendon fibers split lon-
gitudinally. A cannula is used
to protect the patellar surface
during passage of the entry
drill, reamers, and tibial nail.
While there are no reported
long-term clinical outcomes
of this technique, cadaveric
investigations have shown it to
be a safe technique.11,12

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Figure 9: An extensile medial knee arthrotomy is performed to allow lateral subluxation of the patella. By moving the
patella out of the way, the knee can remain extended while an awl or drill is used to create the entry site. Figure 10:
Lateral fluoroscopic image showing the retropatellar portal technique for tibial nailing.
CONCLUSION
Obtaining and maintaining
an acceptable reduction of
proximal third tibial fractures
can be problematic. Deforming
forces acting on the proximal
fragment and the spaciousness
of the intramedullary canal at
this level contribute to this
challenge during intramedul-
lary nailing. Several surgical
techniques have been devel-
oped to address this problem,
including the use of a more lat-
eral and proximal starting
point, adjunctive plate fixation,
blocking screws, semiextended
nailing, and most recently the
use of a retropatellar portal ap-
proach. Familiarity with these
techniques is critical to achiev-
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ORTHO0711Hak.indd 535
View publication stats
9 10
ing satisfactory results when
nailing proximal third tibial
fractures.13
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Coming next issue...
sports medicine update
■ trauma update
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