Intramedullary Nail for Open Tibial Fracture

Abstract

The tibia is particularly susceptible to open fractures because of its subcutaneous location. The status of the overlying soft tissue is regarded as the key determinant of fracture management strategy. Intramedullary nailing is widely recognized by the orthopedic community as the treatment of choice for most displaced, open, tibia shaft fractures due to the extent of soft tissue damage and the risk of infection. Both open and closed fractures are amenable to nailing. Occasionally, plates and external fixators are required to manage certain tibial fractures.

This article describes the stabilization of an open tibia shaft fracture using an intramedullary nail. After copious irrigation and debridement of the fracture site, a transpatellar tendon split is used to expose the nail entry point. This is followed by fracture reduction, sequential reaming, and nail insertion and locking. Finally, the technique for proximal tibia traction pin insertion is demonstrated on the contralateral tibia.

Keywords

Tibial fracture; intramedullary nail; open fracture; internal fixation.

Case Overview

Background

Fractures of the tibial diaphysis can occur across the age spectrum and can present as the result of a variety of accidents. They range from high-energy, comminuted fractures often in younger patients to spiral fractures commonly seen in older patients from lower energy mechanisms. Tibia shaft fractures are commonly treated by both intramedullary (IM) nails as well as a screw and plate construct. Both methods have been shown to be effective and have a low risk of infection.^1-4 Many times when the fracture is open, often in a younger patient from a high energy mechanism, an IM nail is preferred as it is less traumatic to the surrounding soft tissues.¹ Here we describe the indications and methods for IM nail use in an open tibia shaft fracture.

Focused History of the Patient

These injuries are often the result of high-energy mechanisms, with motor vehicle collisions and sports accidents making up about 60% of cases and falls or assaults accounting for another 20% in one study.⁵ A full history should be obtained with details surrounding the event. Examples of relevant details could be if this patient was the driver or passenger, if restraints were worn, if airbags deployed, if there was a loss of consciousness, or if the patient had ever had any previous injuries or surgeries to the affected leg. All of these items can help guide the secondary exam and could have an effect on surgical planning. It is also important to evaluate the patient’s mental capacity and ensure injury or intoxication is not going to affect their ability to give informed consent. 

Physical Examination

Primary Exam:

It is important not to allow an open fracture to distract from a complete physical exam. Once the fracture site is evaluated, it should be cleaned of gross debris and contamination and washed with sterile saline. The attempted reduction should be done to try to keep the exposed bone covered with soft tissue and pressure of the skin in an effort to avoid skin necrosis. A neurovascular exam should be obtained, especially distal to the fracture site. If needed, a Doppler ultrasound can be used to determine if perfusion is intact distally. Any concern of disruption should prompt immediate vascular surgery consultation and a CT angiography to ensure vascular patency. It should be noted that on some occasions, reduction of a severely displaced fracture can allow for the return of perfusion in instances where there are no palpable pulses distally. Evaluation of sensation and motor functioning can help determine the extent of soft tissue damage prior to entering the operating room to help manage operative planning and postoperative expectations.

Secondary Exam:

Because these are often a result of high-energy traumas, there are frequently concomitant injuries present in these patients. A thorough secondary exam is of vital importance to help prioritize care. In some instances, damage control orthopedic (DCO) care will need to be utilized. This might involve placing external fixation or skeletal traction temporarily while other injuries are addressed. It is also important to frequently check compartments on these patients as injuries of the tibia can result in compartment syndrome of the leg, even in open fractures. 

Imaging

Plain films are often used to characterize the location of the fracture and the fracture pattern. Images of the knee and the ankle should also be obtained in order to rule out any injury to the adjacent joints.

Options for Treatment

A fracture is described as “open” when there is a violation of the overlying skin. These injuries necessitate a trip to the operating room as there is a need for intraoperative irrigation and debridement, in which sterile saline is run into the wound to clean it out of any debris, and dead or devitalized tissue is removed. Using a construct from plate and screws is possible and favored by some, but IM nails are generally preferred in these instances as they allow for immediate weight-bearing and reduce soft tissue violation.^1,2 It has been demonstrated, however, that there is a greater risk for malalignment with an infrapatellar nail than with a suprapatellar nail or a plate and screw construct.¹ 

Rationale for Treatment

Indications for IM tibial nailing are the following: tibial shaft fractures, proximal and distal tibia fractures, open fractures, polytrauma patients. The goal of using an IM tibial nail is to achieve a reduction of the fracture site and provide a way to maintain that reduction postoperatively. IM nails also allow patients to immediately put weight on their extremities and allows for the earlier return of function, and decreased risk of complications, such as blood clots.⁶ Additionally, IM nails of the tibia have been found to have shorter operative times and are easier to remove.³ The disability score between nailing and plating at six months has been shown to be no different.⁷

Special Considerations

As mentioned previously, in some instances of polytrauma, DCO is needed. This may alter the typical course of care that the patient would otherwise have received.

Contraindications for intramedullary nailing include the following: open epiphyses, small medullary canal, deformity (eg. prior malunion), grossly contaminated open or infected fractures, fracture in line of locking screws, an associated femoral neck fracture.

If the medullary canal is deformed prior fracture or due to developmental abnormality nailing may not be possible.

Reaming during intramedullary nailing in high trauma patients carries several risks. If severe bacterial contamination or infection are present, nailing may spread infection through the medullary canal, and should be avoided. External fixator pins are a common source of contamination. If such pins appear to be infected, or have been present for more than 2–3 weeks, preliminary pin removal, debridement, and antibiotics may be advisable before nailing. Also it  can increase the risk of infection, particularly in open fractures, due to the disruption of the medullary blood supply and potential contamination.¹³ The process of reaming leads to bone overheating which may result in thermal osteonecrosis. Reaming results in increased intramedullary pressure and secondary embolization of marrow elements to the pulmonary system leading to pulmonary embolism. Intramedullary nailing in severe trauma may cause respiratory distress.^14,15

Reaming can be considered reasonably safe under the following conditions: the patient is hemodynamically stable, the fracture is closed (thereby reducing the risk of contamination), appropriate aseptic techniques are employed, and the surgical team is experienced.

The frequency of tibial nonunion after intramedullary nailing ranged from 3% to 48%.¹² Active smoking, a residual interfragmentary gap > 5 mm, and an initial open wound are risk factors for postoperative complications after intramedullary nailing.¹¹ Other risk factors include fracture type (eg. pathological fractures, such as metastatic bone disease), pre-existing conditions (eg. diabetes melitus), higher TFI ration (the ratio of fracture site diameter to tibial isthmus diameter), and age.

Complications of intramedullary reaming include deep wound infection, malalignment, intraoperative fractures, non-union, malunion, delayed union.¹⁶ Knee pain is the most common complication after intramedullary nailing which occurs during the patellar tendon splitting and paratenon approach.¹⁷

Surgical Anatomy

The proximal tibia is triangular, with a broad metaphyseal region narrowing distally. The tibial shaft articulates with the talus, fibula, and distal femur. Key arteries include the anterior tibial artery, which becomes the dorsalis pedis, and the posterior tibial artery, ending as the medial and lateral plantar arteries. The peroneal artery terminates as the calcaneal arteries.

Nerve supply is critical: the tibial nerve innervates the posterior compartments, while the common peroneal nerve splits into superficial and deep branches, serving the lateral and anterior compartments. The saphenous nerve innervates the medial foot and leg.

Muscles include the popliteus, tibialis posterior, flexor digitorum longus, and flexor hallucis longus in the deep compartment; gastrocnemius, soleus, and plantaris in the superficial posterior compartment; peroneus longus and brevis in the lateral compartment; and tibialis anterior, extensor digitorum longus, extensor hallucis longus, and peroneus tertius in the anterior compartment.¹⁷

Procedure Summary

Once the patient is in the operating room, it is necessary to further open the wound and debride the fracture site and surrounding soft tissues. The incision should be big enough to expose the zone of injury. Once exposed, use a curette to debride necrotic tissue, and irrigate with 3–12 L of normal saline. After irrigation is complete, move on to obtaining the reduction of the fracture. It is crucial to emphasize that after wound irrigation, re-draping and changing equipment are essential steps to maintain asepsis. These practices significantly reduce the risk of postoperative infections by preventing the introduction of contaminants into the surgical site.^18,19

A triangle can be used to help position the leg in a manner most conducive to obtaining and maintaining reduction while still being able to use intraoperative fluoroscopy. The knee is kept in a flexed position in order to gain access to the proximal tibia where the nail will be inserted. 

Mark out the opening incision with a marking pen. The incision for a transpatellar tendon approach is made using the anatomic landmarks of the inferior pole of the patella and the tibial tuberosity. The incision can be made in two passes, with a more superficial incision through the skin followed by a more aggressive deep incision to the level of the tibia. Care should be taken to only violate the tendon in the direction parallel with its fibers to facilitate closure and minimize tendon damage.

Following the opening incision, use a guidewire freehand to gain entry into the IM canal of the tibia. This should be started as far posterior as possible while still staying anterior to the articular portion of the plateau. It should be placed along the anatomic axis of the tibia and tapped into place using a mallet. In this approach, the desired starting point is just anterior to the articular surface of the tibial plateau and just medial to the lateral tibial spine on an AP knee view, with the entry wire parallel to the anterior tibial cortex to neutralize the anterior vector.^18,19 The position should be checked with fluoroscopy in order to verify starting point and trajectory before advancing the guidewire. 

Once it is verified in both anteroposterior and lateral views that the starting point and trajectory are acceptable, use a power wire driver to advance the wire. It is crucial to confirm that on fluoroscopic images the level of the ankle joint, the ball-tipped guide wire is well-centered both on the anteroposterior as well as the lateral view.^18,19 Once the wire is in the desired position within the canal, use the opening reamer to clear cortical bone from the path of the nail. Take care to fully seat the tissue protector against the cortical bone to spare iatrogenic damage to the articular cartilage and the surrounding soft tissues. 

Next remove the opening reamer, tissue protector, and wire and insert a ball-tipped guide wire to the level of the fracture. Use fluoroscopy to ensure the wire stays within the IM canal and does not exit through the fracture site. A small bend can be placed on the wire below the ball in order to help in directing the wire to the desired location. A T-handle chuck and mallet can be used to help drive in the wire if needed. The wire should be driven distally within the canal as centrally as possible to a point just proximal to the physeal scar above the plafond. 

A ruler is then used over the wire in order to determine the length of the nail that is needed. The ruler should be seated all the way down on the cortical bone. Once the length of the nail is determined, reaming of the canal is needed. This allows for a better fit of the nail that fills the canal and provides better internal support. The smallest reamer should be placed over the guidewire and seated on the cortical bone before being attached to the power driver. A wire pusher should be used when backing the reamer out to maintain the wire’s position within the IM canal. Flexible reamers can be used if needed. When removing the reamer, it should be stopped within the canal proximally and removed by hand in order to protect the soft tissues. Reaming should be increased incrementally until chatter is observed at the diaphyseal isthmus.

Once the nail diameter is determined, it can be placed over the guidewire and into the IM canal. A strike pad attached to the nail can be used to allow for malleting the nail into place.

Once the nail is determined to be in the desired location using fluoroscopy, the targeting jig can be affixed, which will allow guidance in placing the interlock screws. A triple sleeve can be used in the jig to determine the entry point in the skin, and then an incision can be made with a skin knife. A Kelly clamp or hemostat can be used in the incision to clear away soft tissue from the screw path. Once done, the triple sleeve can be placed back in the jig and seated against the cortical bone. The middle piece of the triple sleeve is then removed and a drill is used to drill through both cortices. The depth can be measured off the drill depth guide or by hand, and the appropriate length screw should be introduced to lock the nail. This should be done for the available interlock screw positions. An acorn driver should then be used to remove the handle of the nail once the interlocks have been placed. The proximal interlocking screws can be used to fix the nail in the proximal bone, while the distal tibial fragment can be manipulated to obtain desired fracture reduction.

Considering the use of femoral distractor, reductions tools, percutaneous clamping, blocking screws, and supplemental plate fixation to aid in reduction and fixation. These can be combined to optimize outcomes.^18,19  Common tools to obtain reduction are the point of reduction clamps, axial traction, and rotation. Once this is done, the distal interlock screws should be placed to maintain the reduction. The distal interlock screws are placed using the perfect circles technique.

To minimize the risk of common peroneal nerve palsy during the placement of proximal medial-to-lateral oblique interlocking screws, surgeons should use fluoroscopic guidance with the image intensifier angled perpendicular to the drill bit. The thin cortical bone of the proximal tibia and the close proximity of the fibular head can obscure tactile feedback, making it difficult to detect far cortex penetration. Screw length should be confirmed with a depth gauge, and lengths over 60 mm should raise suspicion for posterolateral prominence, risking nerve injury. For distal anterior-to-posterior interlocking screws, careful placement of the surgical incision and soft tissue dissection is crucial to protect the anterior neurovascular bundle, anterior tibial tendon, and extensor hallucis longus.^18,19

Once all interlocking screws are placed, leg lengths should be checked to ensure symmetry and rotation are appropriate. Final X-rays should be obtained to ensure reduction has held and all implants are in their desired locations. 

Following confirmation that all implants are in place and reduction has been achieved, the wounds can be irrigated and closed. Deep closure can be done with Vicryl as demonstrated here. Care should be taken in closing the patellar tendon. Nylons or staples can be used to close the skin. 

The patient is able to immediately bear weight following tibial IM nail placement. Nylons or staples should be removed two weeks postoperatively.

Discussion

Tibial shaft fractures often occur in the setting of high-energy trauma and can have concomitant injuries, often requiring damage control orthopedics and staged procedures.^8,9 Because of the scant amount of tissue covering the anterior tibia, these can often present as open fractures. Long bone fracture management is a crucial aspect to stabilizing a patient and internal stabilization using an IM nail within the tibia is an excellent option for definitive fixation following tibial shaft fracture as it allows for immediate weight-bearing as well as necessitates minimal soft tissue disruption.⁸ Each patient should be evaluated on a case-by-case basis to prioritize the order and manner in which the injuries should be addressed. Generally, the outcomes are favorable for these procedures. The SPRINT trial investigated prognostic factors that can help stratify outcomes for patients preoperatively. These factors are high energy trauma, a fracture gap, full weight-bearing postoperatively, use of a stainless steel implant (as compared to titanium), and open fractures with the reamed insertion of an implant. However, reaming was found to be of benefit to closed fractures. Additionally, open fractures that were able to be closed and required no additional soft tissue procedures were not found to be statistically different for adverse outcomes.⁹ This procedure is common to orthopedic surgery as the tibia is the most frequently fractures long bone in the body and is generally well tolerated with good outcomes. This has been an overview of the indications, common presentations, and operative details for placement of a tibial IM nail using a transpatellar tendon split approach in the setting of an open tibial shaft fracture. 

Equipment

• Ball-tipped guidewire
• Portable fluoroscopy system
• Flexible reamers
• Tibial nails 
  
• Interlocking screws

Disclosures

Nothing to disclose.

Statement of Consent

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.