Session VII - Tibia

Nailing Proximal and Distal Tibia Fractures

Paul Tornetta, III, MD; David Casey, MD; William R. Creevy, MD, Boston Medical Center, Boston, MA

Introduction: Intramedullary nailing generally results in excellent alignment of midshaft tibial fractures because the fit of the nail within the canal maintains alignment. As fractures become more proximal and more distal, alignment is more difficult to obtain due to the lack of friction fit of the nail. Recent reports have demonstrated malunions to be common, and several methods of avoiding these complications have been suggested. The purpose of this study was to examine the efficacy of intramedullary nailing of proximal and distal tibia fractures in a large series along with a detailed evaluation of complications and methods of avoiding them.

Methods: Over a 7-year period, 73 proximal and 81 distal fractures were treated with intramedullary nailing. Fractures were considered proximal if the fracture was within 5 cm of the proximal locking screws and distal if within 5 cm of the distal locking screws. Twelve had fractures that extended into the knee or ankle joint with minimal or no displacement. Seventy-eight of the fractures were open, 32 proximal and 46 distal. Of the 24 extremities with ipsilateral proximal and a distal fractures (segmental), 20 were open. All nailing was performed on a radiolucent table with the leg free draped. A proximal portal was utilized in all cases. Proximal fractures were nailed in relative extension if flexion led to anterior angulation (42 cases), and blocking screws were used to correct posterior translation in 18 cases. Distal fractures were nailed in hyperflexion and blocking screws were used in 8 cases. Alignment was maintained by clamp placement (62 cases) or temporary unicortical plates (3 cases) in open fractures. Percutaneous clamp placement was used frequently for closed distal fractures. The majority of the patients were multiply injured.

Results: Fifty-eight proximal and 65 distal fractures were followed to union (average followup 1.9 years). One patient had a delayed amputation, 3 patients patients died, 10 are healing but not united, and 17 were lost to followup. Complications included malreduction/malunions 5° in 6 proximal and 7 distal fractures which were present on the postoperative radiographs. Increased comminution at the fracture site occurred in 8 cases including one with intra-articular extension. Secondary procedures were necessary to obtain union in 4 proximal and 6 distal fractures. Four of the distal fractures that were dynamized required secondary exchange nailing due to shortening of the fracture and proximal nail protrusion. One nail failed at the distal fracture site and required 2 exchange nails to gain union. Overall, 15 patients had delayed unions (> 9 months) and the remainder healed by 9 months. Time to union ranged from 52 to 472 days for proximal fractures and from 51 to 587 days for distal fractures. In cases of segmental fractures, the proximal fracture healed first in all but 2 cases. Late complications included 2 superficial and 1 deep infection (all open fractures), 1 nail breakage, and 1 case of severe equinus requiring surgical release. Seventy-six percent of the patients returned to their pre-injury job or activities, and 32% had some complaints of stiffness or fracture site pain. Twelve patients deemed themselves incapacitated; however, this was not substantiated by objective findings in 8 of them.

Discussion: The techniques used to nail proximal and distal fractures have evolved over the past 7 years. With careful technique, both proximal and distal fractures can be nailed with good alignment. Open fractures are easier to maintain reduced due to direct fracture access. The complication rate seen in this series is consistent with the rates seen in midshaft fractures. The series demonstrates the evolution of treatment, as all but 2 of the malunions occurred in the first half of the series. The use of blocking screws as described by Krettek and Cole is a useful adjunct to nailing proximal and distal fractures. Likewise, nailing proximal fractures in relative extension, if flexion creates anterior angulation, alleviates the pull of the extensor mechanism avoiding anterior angulation. The use of percutaneous clamps and the femoral distractor for distal fractures aids in maintaining the alignment during nailing. Dynamization, or even dynamic exchange nailing of distal metaphyseal fractures may lead to shortening and nail protrusion even if apparent contact is present.

Conclusion: Proximal and distal fractures can be nailed without a high malreduction rate if careful technique is used, as demonstrated by the learning curve seen in this series. The use of external devices and blocking screws is of great help. The complication rate for intramedullary nailing of proximal and distal fractures is similar to that of midshaft fractures.