Tibial shaft fractures are common. Intramedullary nailing is the procedure of choice for fractures of the tibial shaft. Proximal tibial fractures are noted to produce deformities when an IM nail is used. There are deforming forces in the proximal tibia (patellar tendon), also the wide intramedullary canal of the proximal tibia contributes to the deformity. Proximal tibial fractures are noted to produce deformities when an IM nail is used.
Intramedullary nailing can cause two types of deformities known as valgus and procurvatum.
Surgical approaches include:
- Lateral Parapatellar
- Semi-extended knee position-- the incision may be used with the knee in about 15 degrees of flexion
- Retro Suprapatellar (Transquadriceps approach)-- avoid trochlear injury
Entrance for the IM nail should be in line with the medial border of the lateral tibial eminence. Surgical techniques to help with the IM nail include the unicortical temporary anterior plate, external fixator, and blocking screws.
Blocking screws are very helpful for reduction of the fracture during nail insertion. The blocking screw is posterior to the proposed nail site from medial to lateral in order to prevent procurvatum. Another blocking screw is inserted lateral to the central axis of the tibia (to prevent valgus deformity). The point of entry is usually lateral. Using blocking screws will prevent valgus and procurvatum deformity of the proximal tibia. Another set of locking screws are used through the rod proximally and distally.
