Tibial shaft fracture extending into the plafond—intramedullary fixation

Tibial shaft fracture extending into the plafond—intramedullary fixation

1. Case description

    

   a

    

    

   A 25-year-old woman landed forcefully with a twisting motion on her left foot in shallow water while kitesurfing. She had no previous medical history. Her leg was placed in a vacuum splint and she was transported by ambulance to a nearby hospital.

   Clinical examination revealed deformity of her left leg. The injury was closed and there were no neurovascular issues or other injuries. Subsequent x-rays taken revealed an AO/ OTA 42B diaphyseal fracture of the tibia and fibula (Fig 2.4-1). Upon closer inspection, a fracture line was suspected in the ankle joint. Therefore, a computed tomographic (CT) scan of the distal tibia was performed, which revealed an additional nondisplaced fracture of the posterior tibia at the level of the ankle joint (Fig 2.4-2).

    

   a

    

    

   b

    

    

   b

    

    

   c

    

    

   Fig 2.4-1a–b Postinjury x-rays.

   1. AP view.

   2. Lateral view.

   Fig 2.4-2a–c Computed tomographic images.

   1. Axial view, 5 mm above the pilon.

   2. Axial view at the level of the pilon.

   3. Sagittal view.

    

    

2. Preoperative planning

    

   Indications for surgery

   The surgical indication for a multifragmentary tibial fracture in an adult patient is well established. Nonoperative management may lead to unacceptably high rates of displacement with malunion or nonunion. In addition, prolonged joint immobilization may lead to stiffness. Tibial shaft fractures may be safely managed with an intramedullary (IM) device. While insertion of tibial IM nails has the known side-effect of knee pain, the main advantages of nailing are:

   • Little damage to the soft-tissue envelope

   • The ability to commence early weight-bearing, range-of-motion (ROM) exercises, and rehabilitation

      

     Based upon the extent of the fracture into the tibial articu-lar surface, a preoperative plan was made (Fig 2.4-3). In this case, the ankle joint surface was addressed with a percutaneous screw fixation and stabilization of the tertiary fragment, followed by an IM nail. Failure to stabilize the posterior tibial fracture at the ankle joint can lead to secondary joint displacement through insertion of the IM tibial nail.

3. Operating room setup

    

    

   Patient positioning • Supine on a radiolucent operating table with

   the foot brought to the end of the table

    

   Anesthesia options • General or spinal: if spinal is chosen, the

   drug used should be short-acting to allow for monitoring for compartment syndrome post surgery.

    

   C-arm location • C-arm and monitor on the opposite side of the table to the surgeon

    

   Tourniquet • A well-padded tourniquet may be applied to

   the thigh but is probably not needed in most cases.

   • Use of tourniquet while reaming the IM canal remains controversial.

    

   Tips • Large point-to-point reduction (Weber) clamps, and positioning triangle are useful for fracture reduction positioning the bent knee bend and during fracture reduction.

    

    

   For illustrations and overview of anesthetic considerations, see chapter 1.

    

   Equipment list

   • Screws and K-wires as per surgeon preference

   • Intramedullary nail system with reamers

      

      

      

      

      

     c

      

      

     a b

     Fig 2.4-3a–c Preoperative plan.

     1. AP view.

     2. Lateral view.

     3. Axial view.

      

      

4. Surgical procedure

    

   Following anesthesia and antibiotic prophylaxis the patient is positioned supine. Using the C-arm, a mortise view of the ankle is obtained: the foot in neutral position at the leg and rotated internally 15°. A small anterolateral skin incision is made using the tip of a #15 blade. The incision is deepened using a small clamp until the anterior cortex is reached. The correct position is found using the C-arm and an appropriately sized hole (based on screw size) is drilled into the posterolateral fragment using a drill guide/soft-tissue protection sleeve.

    

   For this patient, a partially threaded screw was used to obtain compression at the fracture. If the fracture is displaced, a reduction clamp placed percutaneously can be used to hold the reduction prior to screw insertion. In this case, the fragment was well aligned, and reduction was not necessary.

    

   Following stabilization of the distal fracture, the leg is flexed at the knee using a triangular stand. A longitudinal midline incision is made over the patellar tendon and the tendon is split. The correct entry point is established using AP and lateral views, and the cortex is opened. A guide wire is inserted and positioned in the center of the distal tibia on both AP and lateral views. The IM canal is reamed 1–1.5 mm larger than the diameter of the chosen tibial nail. In this patient, an 11 mm nail was inserted.

    

   The nail was locked distally with two screws placed using freehand “perfect circles” technique under C-arm guidance. For a simple fracture pattern, one screw may be used proximally, however, for the patient in this case, three proximal screws were inserted. The wounds were irrigated and closed in layers.

   • The surgeon should regularly check for rotation deformity during the procedure. The contralateral leg can be sterile draped into the field for comparison of rotation and alignment.

   • For more proximal or distal fractures, use of small incision open reduction and (temporary) small plate fixation allows for a perfect reduction. In addition, more proximal or distal fractures may require additional locking screws through the nail to maintain alignment.

      

     Complications

   • Postoperative wound infection and deep medullary infection:

     – The surgeon must check for sequestrum and construct stability. If there is loosening, the implant should be converted to an external frame (Fig 2.4-4)

   • Screw malpositioning (eg, too long locking screws)

   • Insufficient reduction or stabilization of posterior malleolus

   • Loss of reduction of the fracture in case of insufficient stability

   • Delayed or nonunion

   • Anterior knee pain at nail insertion site

   • Failure to recognize and treat compartment syndrome

   • Injury to tendons, vessels, and nerves at the anterior aspect of the tibia through clamping (if performed) and percutaneous screw insertion

      

      

     a

      

      

5. Pitfalls and complications

    

   Pitfalls

   • Although IM nailing is a commonly performed procedure, adequate positioning, with the use of the C-arm, is key to a successful outcome.

   • The nail entry point should be chosen precisely, and the guide wire should be in the middle of the tibia, just above the plafond, in the center on both AP and lateral images.

   • Improper entry localization or failure to ream in a center (AP)-center (lateral) manner distally may cause malreduction and subsequent malunion of the fracture.

    

   b

    

    

   Fig 2.4-4a–b Example from a different case showing unicortical external fixator placement after late infection of the IM nail.

   1. Unicortical external fixator following removal of an infected IM nail.

   2. Unicortical external fixator and polymethylmethacrylate nail IM and spacer at fracture site.

       

       

6. Alternative techniques

    

   Instead of an IM nail, less invasive plate fixation can be used. This option requires intact anteromedial soft tissues and allows for a lag screw over the fracture if not too

    

   a

    

    

    

   c

    

    

    

   d

    

    

   comminuted. Plate fixation might be advisable in a case of more severe extension of the fracture line(s) into the plafond (Fig 2.4-5).

    

   b

    

    

   e

    

    

   Fig 2.4-5a–i Example of a different case showing treatment with plate fixation.

   a–b X-rays in AP (a) and lateral (b) views show a spiral fracture distal third tibia and proximal fibula. Note the staples at the lateral side used following release of all four compartments via a single lateral incision as this patient also had compartment syndrome of the lower leg.

   c–e Axial and sagittal CT scan images at the level of the ankle joint show a more significant injury at the level of the ankle: axial view 5 mm above the pilon (c); axial view at the level of the pilon (d); sagittal view (e).

    

   f

   g

    

    

    

   h

   i

    

    

   Fig 2.4-5a–i (cont) Example of a different case showing treatment with plate fixation. f–g Intraoperative AP (f) and lateral (g) images showing K-wires for cannulated screws. h–i Distal plate fixation.

    

    

7. Postoperative management and rehabilitation

    

   Aftercare is similar to that required for a regular tibial fracture. Early full ROM exercise is allowed, and weight bearing is gradually increased.

    

   Follow-up is at 2 weeks for removal of sutures and after 3 and 6 months for radiographic evaluation.

   Implant removal

   Intramedullary implants are not routinely removed due to substantial risk of complications and limited benefit in functional outcome. Generally, the IM component of the fixation construct is well tolerated. If symptoms develop it is usually only at the sites of the interlocking screws. These may be removed if they are symptomatic after union is present. If delayed union is present, removal of cross-lock screws may be considered for dynamization of the rod.

    

   This patient healed uneventfully (Fig 2.4-6 and Fig 2.4-7). The nail was removed 1 year after injury at the request of the patient.

    

   a

   b

   a

   b

    

    

   Fig 2.4-6a–b Postoperative x-rays of the ankle in the 25-year-old treated with intramedullary fixation showing adequate reduction.

   1. AP view.

   2. Lateral view.

   Fig 2.4-7a–b Follow-up x-rays of the 25-year-old treated with intramedullary fixation at 3 months showing maintenance of reduction over time with interval healing of the fracture.

   1. AP view.

   2. Lateral view.

    

    

    

8. Recommended reading

Backes M, Dingemans SA, Dijkgraaf MGW, et al. Effect of antibiotic prophylaxis on surgical site infections following removal of orthopedic implants used for treatment of foot, ankle, and lower leg fractures: a randomized clinical trial. Jama. 2017 Dec 26;318(24):2438–2445.

Georgiadis GM, Ebraheim NA, Hoeflinger MJ. Displacement of the posterior malleolus during intramedullary tibial nailing. J Trauma. 1996 Dec;41(6):1056–1058.

Hou Z, Zhang L, Zhang Q, et al. The “communication line” suggests occult posterior malleolar fracture associated with a spiral tibial shaft fracture. Eur J Radiol. 2012 Mar;81(3):594–597.

Hou Z, Zhang Q, Zhang Y, et al. A occult and regular combination injury: the posterior malleolar fracture associated with spiral tibial shaft fracture. J Trauma. 2009 May;66(5):1385–1390.

Konrath G, Moed BR, Watson JT, et al. Intramedullary nailing of unstable diaphyseal fractures of the tibia with distal intraarticular involvement. J Orthop Trauma. 1997 Apr;11(3):200–205.

Kukkonen J, Heikkilä JT, Kyyrönen T, et al. Posterior malleolar fracture is often associated with spiral tibial diaphyseal fracture: a retrospective study. J Trauma. 2006 May;60(5):1058–1060.

Rammelt S, Boszczyk A. Computed tomography in the diagnosis and treatment of ankle fractures: a critical analysis review. JBJS Rev. 2018 Dec;6(12):e7.

Robinson CM, McLauchlan GJ, McLean IP, et al. Distal metaphyseal fractures of the tibia with minimal involvement of the ankle.

Classification and treatment by locked intramedullary nailing.

J Bone Joint Surg Br. 1995 Sep;77(5):781–787.

Vallier HA, Cureton BA, Patterson BM. Randomized, prospective comparison of plate versus intramedullary nail fixation for distal tibia shaft fractures. J Orthop Trauma. 2011 Dec;25(12):736–741.