Session VII - Tibia

Intramedullary Nailing of Proximal Quarter Tibia Fractures

Sean E. Nork, MD; David B. Barei, MD; Jason L. Schrick, BS; Sarah K. Holt, MSPH; Thomas A. Schildhauer, MD; Bruce J. Sangeorzan, MD; Harborview Medical Center, University of Washington, Seattle, Washington, USA

Purpose: Treatment of proximal tibial fractures remains problematic. Intramedullary nailing of proximal third tibial fractures has been associated with malalignment, nonunion, and the need for revision fixation. We report the results of intramedullary nailing of tibial fractures involving the proximal 25%.

Methods: Over a 36-month period, 456 patients with fractures of the tibial shaft (OTA type 42) or proximal tibial metaphysis (OTA type 41A2 and A3) were treated operatively at a level I trauma center. Forty-two of these fractures involved or extended into the proximal 25% of the tibia. Three fractures were treated with plates and two fractures were treated with external fixation. The remaining 35 patients with 37 fractures were treated primarily with intramedullary nailing of the proximal quarter tibial fracture and comprised the study group. Thirteen fractures were open. There were 28 men and 7 women, ranging in age from 19 to 73 years (mean, 42). All radiographs were evaluated by two orthopaedic traumatologists, and the following variables were measured: total tibial length; proximal extent of the fracture; fracture classification; healing; preoperative, postoperative, and final alignment; and reduction in two planes. An angular malreduction was defined as greater than 5° in any plane. Three fractures had proximal intraarticular extensions, and 22 fractures had segmental comminution. In order to improve control of the proximal segment, 13 patients underwent plate application in addition to intramedullary nailing. These plate were removed after nailing from 3 patients, and in the other 10, the plates were left in place. Lag screws were used to augment the fixation in an additional three patients.

Results: These fractures extended proximally to an average of 17% of the tibial length (range, 4% to 25%). The average distance from the proximal articular surface to the fracture was 67.8 mm (range, 17 mm to 102 mm, not corrected for distance magnification). Postoperative angulation was acceptable (average varus 0.4, valgus 0.3, flexion 0.2, recurvatum 0.2°) as was the final angulation (average varus 0.4, valgus 0.4, flexion 0.3, recurvatum 0.3°). One patient had an angular malreduction of 7° of varus. No secondary procedures were required to achieve union.

Discussion: Intramedullary nailing offers an attractive alternative for proximal metaphyseal tibial fractures. The need for additional techniques to accomplish placement of a medullary device in a reduced fracture was quite common. The most common technique (35%) was temporary or permanent short plate fixation placed extraperiosteally to control the proximal fracture with nail passage. Loss of reduction did not occur and healing progressed despite additional fixations. Complications were uncommon.

Conclusions: Despite reports of malalignement in 58 to 84% of proximal tibial fractures, intramedullary nailing can remain a safe and effective technique. Alignment can be well maintained despite the short segment of the proximal tibia. Simple articular fractures and extensions are not a contraindication to intramedullary fixation. Short plate fixations to maintain this difficult reduction, either temporary or permanent, were effective and not associated with complications.