What is the step-by-step procedure for a closed reduction and internal fixation (CRIF) with intramedullary nailing for a midshaft tibia fracture?

From the Guidelines

Closed reduction and internal fixation (CRIF) with intramedullary nailing is the preferred surgical treatment for midshaft tibial fractures, and it should be performed within the first 24 hours to reduce morbidity and mortality, as recommended by the guidelines for the acute care of severe limb trauma patients 1. The procedure begins with patient positioning in supine position on a radiolucent table with the knee flexed 90 degrees. After standard surgical preparation and draping, a 5 cm longitudinal incision is made over the patellar tendon. The approach can be either transpatellar tendon or medial parapatellar. The entry point is identified at the anterior edge of the tibial plateau, just medial to the lateral tibial spine. A guide wire is inserted at this point and advanced into the medullary canal under fluoroscopic guidance. The fracture is then reduced using manual traction and manipulation, with confirmation by fluoroscopy. Once reduction is achieved, the guide wire is advanced across the fracture site into the distal fragment. The entry point is then reamed, followed by sequential reaming of the medullary canal to 1-1.5 mm larger than the planned nail diameter. An appropriately sized intramedullary nail is inserted over the guide wire and advanced across the fracture site. Interlocking screws are placed proximally and distally through the nail to prevent rotation and maintain length. Typically, two screws are placed proximally and two distally.

Some key considerations for the procedure include:

• Patient selection and timing of surgery, taking into account the presence of severe visceral injuries, circulatory shock, or respiratory failure 1
• Use of temporary stabilisation (external fixator or osseous traction) in cases where delayed definitive osteosynthesis is recommended 1
• Postoperative care, including prophylactic antibiotics and pain management, as well as physical therapy to maintain knee and ankle range of motion
• Prevention of surgical site infection, which can be achieved through measures such as preoperative decolonization protocols and postoperative negative pressure wound therapy (NPWT) 1

The goal of the procedure is to provide excellent stability through load-sharing fixation, allowing for early mobilization while maintaining alignment and rotation, which promotes faster healing and reduces complications compared to non-operative management. In terms of specific details, the procedure should be performed by an experienced surgeon, and the patient should be closely monitored postoperatively for any signs of complications. The use of intramedullary nailing has been shown to be effective in reducing morbidity and mortality in patients with midshaft tibial fractures, and it is recommended as the preferred treatment option 1.

From the Research

Procedure for Fracture Midshaft Tibia by CRIF with Nailing

The procedure for fracture midshaft tibia by closed reduction and intramedullary (CRIF) nailing involves several steps:

• Patient positioning: The patient is positioned supine on the radiolucent operating table with a bump under the ipsilateral hip 2.
• Incision and approach: A 4 to 6-cm longitudinal incision is made 2 to 4 cm directly proximal to the superior pole of the patella, and the quadriceps tendon is sharply incised at its midline and split longitudinally 2.
• Insertion of cannula device: A cannula device with a blunt trocar and protective sleeve is inserted into the knee joint between the articular surface of the patella and the trochlea of the distal part of the femur 2.
• Guide pin insertion: A 3.2-mm guide pin is inserted and placed resting at the junction of the articular surface and the anterior cortex of the tibia at the appropriate starting point in line with the intramedullary canal 2.
• Reaming and nail insertion: The guide pin is advanced, and the cannulated entry drill is passed over the pin through the outer protective sleeve and used to ream down to the metadiaphyseal level of the proximal part of the tibia. The fracture is reduced, and a ball-tipped guidewire is centrally passed across the fracture down to the level of the distal tibial physeal scar. Incremental reaming is performed, and the appropriate-size tibial nail is inserted down the tibial canal 2.
• Interlocking screws: The appropriate nail position is confirmed radiographically, and distal interlocking screws are placed with a freehand technique. The proximal aiming arm is attached to the insertion handle, and interlocking screws are drilled, measured, and placed into the proximal part of the tibia 2.
• Closure: All incisions as well as the quadriceps tendon are closed 2.

Considerations and Variations

• The choice of technique depends on fracture localization, type of fracture, history of concomitant disorders, and soft tissue damage 3.
• Open reduction can be performed if closed reduction is unsuccessful, and it can be safe and effective with respectful handling of the soft tissue envelope 4.
• Regional anesthesia can be used for intramedullary nailing of low-energy tibial shaft fractures, and it may reduce intra-operative opioid requirements without any untoward effects 5.
• The parameters of nursing care extend to pain relief and positioning, nerve and vascular assessments, safe mobility, self-care, and prevention of complications 6.