Intramedullary Nail for Open Tibial Fracture

CHAPTER 1

Can't do a tibial on the outside. Pick ups, please. Yeah. Yeah. Scissors, please. He asked for scissors. I don't wanna use those 'cause they've been in that one. I wanna use fresh stuff over here, okay? Whatever. Can we have a 2-0? And I'll use a stapler here, I think. Staple. Yeah. We're gonna use nylon for that traumatic wound and for the distal inner locks. Yep, knee brace. Is he okay? Yeah. Can I get a pair of scissors? Are these mine? Yeah. So if someone asks you how big an incision you make, you say it exposes zone of injury. Variability issues with this though. Some people would call this a very, it's really not that common. It's a small thing. It's clearly high energy, but... How aggressive are you about taking out devitalized bone? If it's really devitalized, I'll take it out. But you know, if there's any articular attachment or something like that, I'll leave it. You know, if it's a low grade open and it's a very large piece. Do you always vac open wounds, or..? Not always. But in someone like this, who's really had a lot of injury, they're gonna be in the unit, they're coming back to the operating room, she's gonna be catabolic. I like to seal it up. Do you have another 2-0? Yeah. I know there's stuff here, I just don't wanna be holding a needle. A little challenging to get this one reduced perfectly, but we're gonna try our hardest. Mm-kay. Can we have a blue towel, please? That looks like it's pretty well reduced there. There, let's see a suck in there. All right. All right. Triangle. Yep. So another 30 minutes? No. 45. We're half done. That was about an hour, we got another hour.

All right, get the blue. Blue marker, please. Yeah. You just wanted to move that, didn't you? Just a little bit. Here, you wanna really be center, really center. All right, 10? And I'm pretty bold here. You're going down, right? Here, the other way. There you go, 'cause you wanna go down. You can do it in two passes. So make the skin first. Yep, there you go. And now, 'cause you don't wanna saw the skin. But you wanna go down, so it's like that way. Yeah, it's down on... What do you think about the different... I'm gonna make that. I like suprapatellar nailing. I do that for proximal and distal fractures. Good. Guys, do you have that? Now can just take this and put it in there. Like that. Let's see, maybe I can... Just push in, like that. This one a little bit. Oh, sorry. You want the knee flexed. You wanna get as far pushed here as you can, and then in line, so you're right between my fingers there. Yep. Tap, tap, tap. So, you just basically feel this in the middle, right? Yep. Keep going. Good. That's good. And then do you aim a little posterior or just? Just a tiny bit posterior. That looks pretty good.

I'm thinking maybe a little lateral, if anything, but we'll get an x-ray and see. How much have we done? Two. Yeah, we want three for the end. Three for the end. Do you have any preference for transpatellar, lateral... No real difference in knee pain, so I just go straight through, and it's easier. You can make a smaller incision, it's all faster. But why would you go lateral? Or medial. Some people do a medial parapatellar. Just enough to... I think, theocratically to avoid disrupting the patellar tendon. Data shows they're different, so... Repeat in the same hole and it's not gonna give it you you, that's fine. X-ray? Yep, that's fine. See, just make sure you're aiming more medial. A lot more medial. There you go. X-ray? Yeah. There. Just but really careful. You've got a camera on your head, so you gotta go around careful. Yep, that's fine. Yep. Yep. X-ray? Good. X-ray there. Save that. So that's your ideal starting point. That looks really nice. All right, let's come around to our lateral. X-ray there. So that's ideal. Save that. So that's your ideal starting point. That's really nice. Good job. So you're right on the corner, right in front of the articular surface, and you're just on the medial side of the lateral tibial spine. Okay? So that's perfect. All right, so let's open this up. X-ray there. I kind of find it's nice if you drive that down a little bit. The wire's really stiff, and so it kinda finds the canal, and it's gonna make you be a little bit more in line with where you wanna go. Okay. We'll put it on as soon as we go to a different view. Just don't hurt the skin. I'm trying to go towards you. Good. There you go. And then just right in the bone. Just brah. Brah. Just do it. Just go. Just run it into the bone. Go. Push. Then come out. Good. There you go. Like a trauma surgeon. All right. Lots of good work. Do you mind grabbing the light and pushing it down so this comes down a little bit. There you go, perfect. That's perfect. Watch your top, watch your top. Yeah. Good. Oh, whoa. Come down to the fracture, please. Good. X-ray there. Come down a little bit further. Yeah, this is pretty broken. But it's not really stripped. I don't know, two, three A. X-ray. All right, advance that. X-ray there. It's on something there. Watch out. Something there. X-ray there. Shot. Good. X-ray. Come distal, please. X-ray there. X-ray. Mm-kay. X-ray there. X-ray there. We gotta get this out and put a little curve on it, 'cause you're aiming a little bit medial there. So take this out. Look at their ankle. Is that normal? That's me twisting the foot 90 degrees. Do you have a... Do you have the bender? That'll do it. So, no, it's not normal. Look at that tilt there. I'm good. I'm good. Yeah, I don't put a lot of bend in it, just a subtle bend. Just enough to get it to go where you want. You end up getting a malalignment when you put your nail down. Tends to go into varus. X-ray. X-ray. More valgus. X-ray. That's out. That's out, so pull back. X-ray. Try again. X-ray? X-ray. That looks better. Keep going. Good. X-ray. So - get a T-handle on it so you can power it through there. That centered real nice though, I like that. X-ray there. Mallet. Here you go. Tap, tap, tap. Good. X-ray. So now turn it so it's going a little more anterior. X-ray there. So now you gotta turn it a 180. So you gotta, no, no, now you go to 90. X-ray. Now it's, x-ray. There you go. X-ray. There you go. Tap, tap, tap. X-ray. X-ray there. Good. Tap, tap, tap. Just a little bit. Good. X-ray there. So that looks good there. It's aiming right where I want it to. X-ray there. And now you gotta get it over the other way. So 180. There you go. X-ray. Good. So now tap, tap, tap. Yep. Like you mean it. Good. X-ray. See, that's starting to go the right way. And then let's check this way. X-ray. That looks good there. X-ray there. All right. Tap, tap, tap. Like you mean it. X-ray. A little bit more. X-ray. And now hit it like you mean it. You really want it down? Yep. X-ray. All right, I think that's probably okay. You can get it further, but I think it's okay. All right. X-ray there. X-ray. All right, so a little posterior, but I think that's okay. So now what? Come up to the knee, please. What do you need now? Bigger hands. But what equipment do you want next? Now a ruler. A ruler, please. Yep. Ruler? Here's the mallet back. So she's got a pretty small canal. So we're expecting a pretty small nail. Probably about a nine. So we start by measuring so we know the length. And then as you ream, that determines your diameter. X-ray there. Oh, that way. Yep. X-ray there. X-ray. Now you can just measure it. So that says, so what do you want? So they don't come in 320s. Oh, they don't. So 300s plus 15s for a tibia. So this'll be a 315. 315. Yeah. So 315. All right, and then we'll take an A5 and see what happens. Now if we can get to 10, it would be great, but since we put a nine in the femur it's hard to believe we're gonna get to it. Can you find out what nails we have? This is a, what do we say, 315 by eight and 315 by nine are our options that we're gonna use. Have the drill? So I want you to engage that on there first. Can we check and see if we have the tibial set on the - 315 by eight and 315 by nine. Yeah, if you could bring those both in. Just bring them both in. Yeah. Thank you. The left? Left, yep. Thank you. There's no left and right. There's not? No. Come south. Here, I want you to be bringing it this way so you're not hurting the skin, okay? Yeah. X-ray there. Good. Keep going. Keep going. Stop for a second. X-ray. Come up proximal. X-ray there. All right, so let's take that out. And we're gonna have to use the flexible reamers. Don't lose your wire.

We'll have an eight, and then we only have to get to nine. What do you have for us? The smaller of the two. Seven. Seven. All right. That'll be a good start. So it's pretty rare, but sometimes your standard reamer is set to eight five is the end cutting, but every so often you've got a tight canal and you gotta start with one of the flexible reamers. Good. Good. Do we have an eight? I have an eight by 315 and a nine by 315. Let's do an eight. Yeah, we'll do an eight. So I thought you said a left. It doesn't matter. It doesn't matter? Oh, you were just kidding me? Yeah, I was just messing with you. Thanks. Sorry. I was wrong. I'm out there trying to find a right or a left. Yeah. Sorry. For what? Didn't mean to. Yeah, I mean, come on, man. X-ray. Eight by 315, right? Cold PBI. Super cold. Is that an eight? Good. X-ray there. What's the most distal you can fix with a tibial nail? There's like a measurement like 0.5, something like a scar, two. It depends a lot on the fracture and the bone quality. That was eight. You wanna go to nine? Yep. We gotta do eight five, and then nine. So here's your eight five. How much irrigation? A bazillion. Six liters. We have lost very little blood. I'd say it'd be like 200. Excellent orthopedists. Is she opening a nail or running away? Whoa, whoa, whoa, whoa. Come south. We gotta ream all the way down to the bottom now. Come south. X-ray there. Okay. Good. X-ray. Nice. Keep going. Push hard. Push hard. What's that? Push hard. Up. X-ray there. Good. Your wire's coming out, I think. X-ray. Yeah, your wire's coming out, yeah. Mallet. There you go. That's it. That's it. Okay. Yep, go ahead. Do you really got it? Yeah, I already got it. It's spinning. No, it's spinning. Can you get a mallet? I can feel it spinning. You just gotta tap it. Get that thing back down. Try backing up. X-ray there. So part of the problem is you gotta back this out first. Back up a little bit first, and then move back down there? Yep. Back it up a little bit first. Back it up, please. Stop there. Now tap it down. There you go. That's good. X-ray. There you go. Right behind you. Nine, please. Good. All right, we'll take the nail. I like it. Blue. Tap, tap, tap. Mm-hm. X-ray there. Good. Okay. X-ray there. Good. X-ray there. X-ray. Come up proximal just a tiny bit. X-ray there. Nice. All right, good. Let's come up to the knee. Good. Proximal a little bit. Actually, x-ray there. Then come proximal a little bit more. Raise your machine. X-ray there. X-ray there. Good, so you drove your nail down to a good depth. Come down to the ankle again. Let's just make sure we're happy with our depth there. X-ray there. X-ray. X-ray there. Okay. I think we're pretty good. Let's give it just a tiny bit more of a tap. That's good. X-ray there. That's nice. X-ray there. X-ray. X-ray. Can you hold the knee for me? It's kind of hard. X-ray. Yeah, pull it back. Pull it back? X-ray. There you go. X-ray. There, so that's reduced. So we gotta go a little bit further. Come up to the knee. Good. X-ray there. X-ray. X-ray. That's probably pretty good. X-ray. Yeah, I like that. We're good. Okay. Do you have a blue marker? Blue marker? No, we're gonna close it, but we're gonna put an incisional back there. Incision back. 15, please. If that's dull, let me know. All right. Rule guide. Mallet. And then tap, tap. Good. Good reflex you had there. 32. Okay, drill. Oops. Just keep that in there. Fill. 34. 34? Yeah. Maybe even 36 actually. Acorn. Acorn. So that, once you pull it out, actually reduces quite nicely there. Yeah. And it's kind of bone grafted itself there, so we're gonna keep that in there. That's the beautiful about open fractures, you can just see it. Yep, that is correct. It's like cheating. No, but I wasn't really providing any extra. Oof. Next time, you'd never know this, but I like the long one. Okay. No, I tried it. I got stuck in the... Oh. Does the long one work on that now? Yeah. Oh, I don't know, actually, for a small one. X-ray there. Save that. So we have the nail driven down now. You can see it's completely beneath the surface of the bone, which is what we're looking for. But not too far down that if she has an infection or some problem, we can get it out. Come distal. And then the reason why... X-ray there. Keep coming distal. Save that. Come a little bit more distal. X-ray there. X-ray there. X-ray there. X-ray there. Save that. So that's not bad. We're at a tiny bit of recurvatum, but really not bad at all. And then let's come up to an AP. X-ray there. So I like our reduction. All right, come back towards you a little bit. X-ray. So the question now is just a matter of rotation. So our alignment is really nice in that plane. Yeah. X-ray there. That looks really good. This is just a matter of getting the reduction perfect. Do you have one more of these? Can you back out for a second? No, no, I need the... Do you have a Weity? Come on in there. So one of the challenging things here is to get rotation right. Sometimes you can use some of the fragments you had even though it's not perfect reduction. To get close. X-ray there. Back out for a second. So, we're short. Yep, there we go. Now come back in. X-ray there. That's pretty close. Back out again. Do you have a knife? Suck in here. Clinically, I agree with a little bit extra. Turn the foot in for me? Yep, there you go. No more, no more. Less, less. Just real subtle. Sorry. Now I lost it. Just real subtle. Okay. Suck. Pull hard. Okay. Come on in. Regardless, just see how that looks, clinically. So clinically, looks pretty good. We need our kneecap straight up. Looks pretty symmetric. Yeah. Good. X-ray there. Lets get rid of our clamp, yep. X-ray. X-ray. X-ray. Alright let's get a - give me a frog, halfway towards you. Good. X-ray there. Good. Now go lateral. X-ray. Pretty good. I think we have length there. X-ray there. X-ray there. That looks pretty good. Save that. All right. So I like that rotation. Clinically, it looks good. Just direct inspection, it's hard to cobble everything together perfectly. But everything seems to key together pretty nicely there. Once we have pointer reduction clamps, and try to get it slightly better. And you'll take it. Is there any special technique you would do if it's closed? If it's closed. Well, that's the advantage of having the other side in the field, is you get a cheat. You can get x-rays of the other side, AP and lateral of the knee. But it's very, very, hard. Really, the kind of trick that I use the most is getting multiple planes. You know, the cortices should all line up on all your x-rays. X-ray there. X-ray. All right. Let's come up to an AP. You know, it's not reasonable to expect that these are gonna anatomically reduce, because they weren't anatomically reduced when we reamed. Even if they were, the reamer would've pushed them away. And so, the tibia's just, you know, it's real tight, so it's just not gonna fit there. All right, good. So in a situation like this, we need lots of distal locking screws. X-ray there. Come distal, please. X-ray there. Do you have another couple towels? X-ray there. Can you arc over the top a tiny bit? X-ray there. X-ray there. That's good. Knife, please. 15. 15, please. All the AP and the lateral have always looked good, so I'm not too worried about it. X-ray. X-ray. X-ray. No. X-ray. My eyes aren't that good to see it with mag. Uh, no. Close, though. Close. We've got kind of a large wound. We got a large wound. X-ray. X-ray. X-ray there. Depth gauge. X-ray. It's not a regular one. There isn't a small exit though. X-ray. I'm pretty sure I drilled through that, but... Yep, there it is. 44. X-ray. Yep. X-ray. Miss. Yeah, you're not gonna save that one. X-ray there. X-ray. X-ray. X-ray. X-ray. X-ray. May be in it now. I think you were in. No, I don't think so. I think I missed it. I think I got it now though. X-ray. X-ray. X-ray. So that's in there. Yeah. The ankle feels fine. Okay. Yeah. I agreee. All right. Irrigate. Or, x-ray? Do you have a basin for me? Knee in. X-ray there. X-ray there. X-ray there. Screwdriver. We've got two more screws to put in, right? Yeah. X-ray there. Probably could be longer. That's okay. All right. 15 blade, please. Come up, so internally rotate. Yep, actually, come off lateral. That'll help too. Actually, you can relax a little bit. We're just, yeah, there you go. X-ray there. Can you lag south? No go north. Now pull back towards you. Good. Now go north. Now go up. It's too far. Subtle moves here, please. Now go up. Up. Good. X-ray there. Good. You're off mag. X-ray there. Come off lateral, please. There you go. X-ray. There you go. Tiny bit. X-ray there. There it is. Raise your machine a tiny bit. Good. X-ray there. And then, x-ray there. X-ray there. Can you come south just a tiny bit? Yep. X-ray there. X-ray. Lagging. X-ray there. X-ray there. X-ray. X-ray. X-ray. Bullseye. Of all the places in the known universe for your hand to be, that's the worst one. No, it's just you don't wanna be on the far side of the drill. Like that? Yeah, no, I know. But she has Hep C, you know what I mean. You don't wanna be anywhere near it. 36 shot. What was this one we put in the front, the top? 30. The first one? No, this last one we put in. 34. Are you sure? I thought was like 40 something. No, it was 34. Really? Yep. Pretty sure. Well, it needs to be longer than that. That's gonna be a 38. No wonder it's so short. All right. X-ray. I like to take a picture before I drive it home, so I still have access to the screw head to confirm that I'm right on target. That's a nice bite there. Good. Good thing. When they have these sure shot things and all that. X-ray. No. X-ray. Once you get pretty facile with perfect circles. X-ray there. Nope. You gotta internally rotate. X-ray. X-ray there. X-ray there. Just a tiny bit more proximal. X-ray there. It doesn't really give you that much, I don't think. 40. 40? Yep. Yeah, that maybe took a minute. X-ray. But I think if you're a low frequent surgeon, I think maybe some utility to it. But if you're doing a lot of these, it doesn't really. You get pretty used to it quickly. I think it's designed for people in the community. Do I change out that other screw? Yeah. Do we have this smaller? No, maybe she is dislocated. Or she just has a really funny ankle. It's that. Oh, yeah. Come south for me. Yeah, you're right. Right there. X-ray there. Yeah. Internally rotate a little bit. X-ray there. That looks... That looks okay. X-ray there. Let's get an oblique of the foot to be sure, but I think it's okay. Yeah, it's the same. That's just her - she's just flexible. Do you have a Freer? There's that anterior median bordering the tibia, you know that's a nice flat surface of bone. And there's that, you know, that's pretty similar. You know, it doesn't seem like we're turned in or out. There's the crest right there, there's a crest right there. They're lined up pretty well. I think we're pretty good, I think within five or 10 degrees, which is good. So, you don't always perseverate on it. And especially with an accommodated one, it's easy to mess it up. All right, why don't we... That's pretty good. Let's get our final x-rays, and then what I wanna do is get an AP of the knees, make APs of the knees. Oh, yeah. Screwdriver? We actually probably will not end up doing the traction. We'll see in a minute. We're gonna see. Can you measure this and give me a six longer? That kinda doesn't matter anymore. No. Yeah, I hear ya, man. X-ray. X-ray there. X-ray. Can you come to an AP? Yep. X-ray. X-ray. Screwdriver. X-ray.

CHAPTER 2

X-ray there. X-ray there. Will you come up to the knees, please? You know, radiographically, a little concerned about it. It's okay, but not perfect. Above the ankle or above the knee? The rotation, yeah. X-ray there. Could you swap that for me? Can you come back towards you? X-ray there. X-ray there. X-ray there. X-ray there. That's actually pretty similar. You know, there may be a few degrees out, but definitely not far. Not terribly. X-ray there. X-ray there. X-ray there. X-ray there. X-ray there. There. There. No, I mean, you gotta get the rotation right. Yeah, yeah. I think that's pretty good. I think I'm happy there. Okay. Raise the table for us, please. Yep. Coming up. Raise it up higher? That's good. Show me the knee, please. Push in, please. Push in, please. There you go. X-ray. X-ray there. Could you just make that straight up and down for me? Just one click over. The other way. One more click. Good. Save that. Come south. Keep coming south. Good. X-ray there. X-ray there. Pull back towards you a little bit. Yep. X-ray there. Come south. So those screws are long, but I think they're gonna be okay. Yep. X-ray there. No, that one's too long. What a hassle. All right, screwdriver. Go north. Take off four, I guess. The distal one's okay. Here you go. Yep. She's moving around a lot today. All right, come on south again. Show me the fracture. Yep. Come up proximal a little bit. X-ray there. X-ray there. X-ray there. X-ray there. Could you straighten that up for us? Just rotate it around one click or two. The other way. One more. Nope, back a bit. Back one. Back one click. There you go. X-ray. X-ray. X-ray. Save that. X-ray. X-ray. Save that. Come to a lateral, please. x-ray there. Could you drop the table for us, please? Good. X-ray there. X-ray there. X-ray. Save that. Come up proximal a little bit. X-ray. X-ray. Drop that. X-ray. Save that. Come up towards the knee, please. X-ray there. X-ray. Save that. All right. One last thing. X-ray there. Come south even further. X-ray there. X-ray there. All right. So to get a lateral of that, I gotta really twist it in. So that just makes sense. Come up to the knee. X-ray there. X-ray there. Yeah. X-ray there. So it's the same. X-ray there. She's like me, she's got a lot of external tibial torsion. Okay. Good. All right. Thank you. Come on out. We are done with x-ray. Irrigation, please. We got that three liters up, right? Yeah. Nothing more. No traction pin. Well, actually, show me the - I don't think so, show me the hip again. X-ray there. X-ray. X-ray. Come south. Back towards you. There you go. X-ray there. X-ray. X-ray. X-ray. X-ray. We just hold it reduced like that, huh? X-ray. X-ray. Yeah, we can put her in 15 pounds of traction. Won't hurt anything. Just make sure you're down here. I think it's fine. Whoever called us about the traction bow, can you say, "Yes, we need it." All right. Basin. All right, so why don't you get to sewing up there. Get that up. So to do a perfect tibial traction can you go from the fibula have to go basically, can you go from the tibia... So it can go Gerty's tubercle to tibial tubercle and you go like this, and that creates a safe arc. Uh-huh. So it creates an arc. Yeah, like this. So the ideal pin would be right there. Just a little distal. Yeah, just a little distal. You could probably be maybe a little bit, yeah, right about in there. Do we have some local? All right, I will take the nylon or the Vicryl. You want 2-0 or? 2-0, yeah. Adson. I'm cleaning that right now. Can I have a knife, please? Thank you. Half percent with epi, do you care? What's up? For local. Half percent with epi. Sure. Schnidt, please. Knife back. With epi? Yep, that'd be great. Do we have the correct open? There's some scissors out.

Scissors? I need some too. Just don't get it in the fibula. I won't do that. It's been done. Can you get me, do we have a bolt cutter? No. I want that extra pin that's in there. Yep. That's mine. I want you to take a bolt cutter, we're gonna need a bolt cutter, and cut off the tip, and I want this. Okay. And where do you usually like to aim at? Parallel. There you go. Back, please. Yep. Knife back. So Dr. Weaver, post-op pain for her, I'll have them leave the traction on. Non-weight bearing on the right side, weight bearing on the left. Weight bear less now. Not gonna weight bear at all? Transfer only. For a while? All right. Nada. When do you want me to have them make room for you somewhere back here? Monday. So do you need... Plan for Monday? No, it's okay. It's okay. We didn't need that. Had her on for planning of the proximal femur as well as... Yeah. The anti-coag will probably be per nurse. They're coming in pretty well. Yep. We should recommend a filter. Hey, Mark, thank you. That was good. That was good. Thank you. Can I see the bow? Bow coming in with x-ray? We'll do the x-ray real quick. All right, final picture time. Oh, okay. Washi, push in the C-arm, bro. Washi, come here. You're the C-arm man. Washi, push it. I need another 2-0, please. So next time. Come out here. Yeah. Should I do it again? No. It's a little closer. As long as it's enough on bone and bicortical. I'd like another 2-0, please. You wanna go to lateral and finish up right here? Save that. Get a lateral, yeah. X-ray. Save that. Nice shot, man. Looks good. I actually like it. I think it's perfect. I thought maybe you were a little posterior, but I think you're absolutely perfect. It looked, it just looked a little posterior.