– General Discussion of IM Nails
– PreOp Planning
– put
– note rotational alignment of the diametric not injure side.
– cautions:
– proximal tibial fractures ( high complication rate w/ IM complete )
– distal tibia fracture
– IM nail of open tibial fractures
– metameric tibia fractures : / treatment methods for tibial defects
– compartment syndrome
– w/ IM pinpoint, buttocks lens cortex of tibia may be fracture on insertion of pinpoint w/ possible nerve or vascular injury
in later compartment ;
– pin down intramedullary duct ;
– citation :
– Heat-induced segmental necrosis after reaming of one humeral and two tibial fractures with a narrow medullary duct.
– compression bandage :
– compression bandage may aid photograph but is avoided w/ ream, as absence of blood stream increases extent of thermal necrosis ;
– compression bandage may contribute to compartment syndrome and thermal necrosis ;
– references :
– The manipulation of a compression bandage when plating tibial fractures.
– thermal necrosis after tibial ream for intramedullary nail arrested development. A report of three cases.
– anesthesic considerations :
– surgeons should insist on general anesethesia or short spinal anesthesia so that the surgeon can evaluate for postop compartment syndrome ;
– references :
– Does patient controlled analgesia delay the diagnosis of compartment syndrome following intramedullary nail down of the tibia ?
– Differences in attitudes to analgesia in post-operative arm surgery put patients at risk of compartment syndrome.
– compartment syndrome without pain !
– dumb compartment syndrome complicating entire knee arthroplasty : continuous epidural anesthesia masked the pain .
– Patient Position and Fracture Reduction:
– before the font starts, the surgeon should have a plan to obtain frx reduction, noting the sum of assistant and equipement available ;
– status the OR lights off from the center of the table, so that the guidebook wires do not touch.
figure of four position :
– lapp as the arthrscopic position, with hep and knee bend over the opposite stage ;
– minimzes the angulatory displacement in the saggital plane ;
– note that once the proper entrance trap is established ( AP view ), the reduction on the lateral view is most important ;
– w/ proximal or distal fractures, consider need for blocking screws ;
– w/ exposed fractures ( or cases in which a fasciotomy has been performed ) a lineal reduction is performed through the wind ;
– direct decrease is much critical for proximal fractures ;
– if the reduction is unmanageable to achieve, then a cannulated nail system should be used ( both for ream and for nail down interpolation ) ;
– references :
– Does open reduction addition the opportunity of infection during intramedullary complete of close tibial quill fractures ?
– A placement technique for closed intramedullar complete of tibia fractures.
– capable Reduction and Intramedullary Nail Fixation of close Tibial Fractures
– Preparation for Nail Insertion : ( see synthes )
skin incision and exposure
– Suprapatellar Intramedullary Nail Technique Lowers Rate of Malalignment of Distal Tibia Fractures.
entry into the IM canal
reaming of tibial fractures:
– over-reaming by 0.5 to 1 millimeter is probably indicated for all tibial IM breeze through procedures since it helps guarantee proper complete
diameter ( avoiding nail captivity and/or posterior cortex blow out ) ;
– compression bandage should never be inflated during ream of the intramedullary canal, since this risks thermal necrosis ( compression bandage is
rarely needed ) ;
– avoid eccentric reaming:
– remember that the reamer follows put of steer wire and that breeze through follows the path left by the reamer and therefore
template wire position needs to be carefully checked during reaming to make ensure that it is centrally located on two
radiographic views ;
– bizarre ream will cause the complete to enter into the duct eccentrically which will end up induce the distal fracture
shard to move into varus if the ream is eccentric laterally and will cause it to move into valgus if the
ream is excessively median ;
determine nail width:
– this is critical because under-sizing nail diameter will give a free match and over-sizing breeze through may cause nail captivity and
resultant back tooth cerebral cortex frx ;
– ream is the best way to determine collar width ;
– w/ unreamed proficiency, sounds can be used to determine the diameter of the canal and the proper complete size ;
– largest sound that passes well thru the isthmus is decline choice ;
– uncomminuted distal frx may require a smaller diameter nail or ream, as compared to comminuted isthmus frx, because of
long intervention meet within canal ;
– reference : fatigue failure in little diameter tibial nails.
determine nail length:
– this is best determined once the initial starting reamer is placed down the canal ;
– w/ the reamer down the canal, the fracture can normally be reduced no shortening or angulation ;
– consumption flouro to mark proximal submission position at degree of tibial tableland, & distal position at physeal scratch ;
radiolucent ruler:
– measures the proper breeze through distance ;
– remember that if the rule is placed on top of the tibia ( rather beside it ), then there will be a tendency to undersize length ;
pitfalls :
– do not measure nail duration from the proximal tibial joint line but rather measure duration from the breeze through entrance locate ;
– external oblique muscle fractures tend to be shortened at the fracture site and cross fractures or comminuted frx may be distracted ;
– therefore measurement of oblique fractures may cause nails to be shortstop and transverse/comminuted fractures may cause
nails to be excessively retentive ;
– with distal devious fractures often nail ends up being excessively short-circuit ;
– note that a collar that is excessively long may have the effect of distracting the fracture locate, when the tip of the nail engages the
physeal scar continued impaction may distract the fault site ;
– references :
– An easy and accurate preoperative method acting for determining tibial nail lengths
– tibial tubercle-medial malleolar distance in determining tibial nail down distance.

– Insertion of Nail:
– visualize considerations in proximal tibial fractures
– anterior to nail interpolation, test the proximal mesh device to ensure that the drill will pass w/o difficulty ;
– do not allow the nails to touch the hide as it is being inserted.
check the nail progression:
– as the collar is hammered down the canal, its progression needs to be followed on the lateral view ;
– if nail fails to advance with each coke of the forge, barricade, for the nail is impinging on the cortex or it besides big for the duct ;
– attempts to drive it further may fracture the cortex ;
– although the collar may occassionally excessively big, the common causal agent for impingement is improper alliance of the collar within canal ;
– fluorine racture reduction: ( completed a soon as the nail crosses the fracture site ) ;
– miss of cortical continuity ( fracture opening ) is the one major gene that surgeon can control with respect to frx healing ; ( non-union )
– capable fractures and cross fractures are other risk factors for fracture non union ;
– w/ proximal or distal fractures, consider need for blocking screws ;
– references :
– The use of Poller screws as blocking screws in stabilising tibial fractures treated with small diameter intramedullary nails.
– Fractures of the proximal third of the tibial diaphysis treated with intramedullary nails and blocking screws.
– The mechanical effect of blocking screws ( “ Poller fuck ” ) in stabilizing tibia fractures with short proximal or distal fragments after interpolation of small-diameter intramedullary nails.
– technique for precise placement of poller screws with intramedullary collar of metaphyseal fractures of femur and tibia.
– The logic and clinical applications of blocking screws
– [ Effect of blocking screws on breakage of interlocking intramedullary nails ]
– indigence to open the fracture site :
– Does open decrease increase the probability of infection during intramedullary pinpoint of closed tibial shaft fractures ?
– references :
– transdermal cerclage wire and interlocking nailing for treatment of torsional fractures of the tibia
– transdermal cerclage wiring-assisted interlock nail down for torsional tibia fractures : a modification with improved safety and simplicity.
– Intramedullary breeze through of proximal and distal one-third tibial shaft fractures with intraoperative two-pin external fixation
– Predictors of reoperation following operative management of fractures of the tibial diaphysis
– transdermal clamp of coiling and external oblique muscle fractures of the tibial shaft : a safe and effective reduction aid during intramedullary breeze through. .
rotational alignment:
– once the nail down crosses the fracture locate, great care must be taken to restore rotational alliance ;
– use flouro or the bi-malleolar axis to determine proper conjunction ;
– Getting the Rotation Right : Techniques for Assessing Rotation in Intramedullary Tibial and Femoral Nailing
– Findings related to rotational malalignment in tibial fractures treated with ream intramedullary smash
nail centralization:
– as the nail is driven thru the proximal fragment, it is crucial that it centralizes prior to reaching the fault locate ;
– if nail does not centralize prior to reaching fracture site, then remove nail, re-ream the canal, and consider adding a
buttocks bicortical obstruct screw ;
fracture compression:
– once the smash is across the fracture site, place antagonistic coerce across the foot to provide frx compression as the complete is
drive distally ;
– note that fracture compression is chiefly required with mid shaft fractures, where as in contrast, distal one-third fractures need
to be brought out to length and held with two proximal and two distal interlocking screws ;

– Interlocking:
– proximal inter-locking
– distal interlock : prior to distal interlock, ensure that there is optimum frx site compression ;
– two screws should be used if the status of the cheat is within 4 centimeter from the fracture site ;
– references :
– single or double distal lock in intramedullary complete of tibial shaft fractures : a prospective randomized cogitation
– Dynamisation and early weight-bearing in tibial reamed intramedullary complete : Its base hit and consequence on fault coupling.
– Intramedullary smash without interlocking screws for femoral and tibial shaft fractures
 – Post Operative Care:
– if stability of the fracture is in wonder, then below stifle cast immobilization and touch down wt carriage are used until healing ;
– once partial fracture curative has taken place, consider a functional couple or consider a below knee cast with the back of the
foundation and ankle removed to allow ankle dorsiflexion ;
– active dorsiflexion and plantarflexion stresses the tibia and produces displacements exchangeable to wt bear ;
– references :
– Can Tibial Shaft Fractures Bear Weight Following Intramedullary Nailing ? A Randomized Controlled Trial .
– static interlock : most tibial fractures heal in the inactive interlock mode ;
– dynamization :
– removal of proximal or distal screws allows axile load of tibia ;
– regard at 3 months in axially stable fractures with no callus ;
– axially unstable frx should remain in inactive mode and should receive bone transplant ;
– references :
– [ Intramedullary pinpoint of the tibia with the adept tibia complete ].
– Dynamisation and early weight-bearing in tibial reamed intramedullary smash : Its safety and impression on fracture union.

– Complications:
– referee : omen Factors for Predicting Outcomes After Intramedullary Nailing of the Tibia
– non-union
– biggest risk factor for tibial non union following IM smash is fracture mal-position or the presence of a opening at the fracture site ;
– anterior knee pain:
– references :
– anterior stifle pain and thigh muscleman lastingness after intramedullary nail of tibial cheat fractures : a report of 40 back-to-back cases.
– incision placement for intramedullary tibial breeze through : an anatomic study.
– front tooth knee pain after intramedullary nail down of fractures of the tibial cock. A prospective, randomized learn comparing two unlike nail-insertion techniques.
– transdermal intramedullary complete of tibial shot fractures : a fresh overture for prevention of anterior stifle pain.
– Knee pain after intramedullary tibial collar : its incidence, etiology, and result.
– Knee pain after tibial nail down.
compartment syndrome
– citation :
– compartment syndrome without pain !
– infection: ( see infections following tibia fracture )
– if nail removal is required, then consider reaming canal after smash removal as a method acting of debridement ;
– see addition of antibiotics to cement
– references :
– infection after intramedullary collar of the tibia. incidence and protocol for management.
– diagnosis and management of infection after tibial intramedullary smash.
– infection after reamed intramedullary pinpoint of the tibia : a character series revue.
– Intramedullary infections treated with antibiotic cementum rods : preliminary results in nine cases.
– The antibiotic cement breeze through for infection after tibial breeze through.
– antibiotic Cement-Coated Interlocking Nail for the Treatment of Infected Nonunions and Segmental Bone Defects.
– dropped hallux deformity:
– Robinson CM, et aluminum. ( 1999 ) authors performed a prospective learn of 208 patients w/ tibial frx treated by ream IM collar ;
– 11 ( 5.3 % ) developed dysfunction of peroneal nerve, 8/11 showed a ‘dropped big toe ‘ syndrome, with weakness of EHL and
numbness in first web space, but no clinical affair of extensor muscle digitorum longus or tibialis front tooth ;
– there was good convalescence of muscle function within 3-4 months in all cases, but after one year 3 patients still had some
residual meanness of EHL, and two some apathy in the first world wide web space.
– references: 
Dropped big toe after the intramedullary nail down of tibial fractures.
– radiographic analysis of tibial fracture malalignment following intramedullary nail down.
– severe heterotopic bone formation in the knee after tibial intramedullary nail down.

Intramedullary smash of femoral and tibial shot fractures

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