What is the step-by-step procedure for treating a fracture of the distal tibia using Ender's nailing?

Ender Nailing Procedure for Distal Tibia Fractures: Step-by-Step Guide

Ender nailing is a viable treatment option for distal tibia fractures, particularly for simple fractures that are not highly comminuted. While not as commonly used as other fixation methods, this technique offers advantages in certain clinical scenarios.

Patient Positioning and Preparation

1. Position the patient supine on a radiolucent operating table
2. Administer appropriate anesthesia (general or regional)
3. Prepare and drape the affected limb using sterile technique
4. Obtain pre-procedure radiographs to confirm fracture pattern
5. Apply a tourniquet if needed, but ensure it's properly timed

Surgical Approach for Distal Tibia Fractures (Method A)

Step 1: Entry Point Selection

• Make two small incisions (2-3 cm) at the distal tibia:
  • One on the medial aspect of the distal tibia
  • One on the lateral aspect of the distal tibia
• These entry points should be approximately 2-3 cm proximal to the medial and lateral malleoli

Step 2: Creating Entry Portal

• Use an awl to create entry portals in the distal tibia
• Direct the awl proximally toward the fracture site
• Confirm proper positioning with fluoroscopy

Step 3: Nail Selection and Preparation

• Select appropriate Ender nails (typically 3.5-4.5 mm diameter)
• Pre-bend the nails to match the anatomical contour of the tibia
• Ensure the curvature of the nail matches the intended path

Step 4: Nail Insertion

• Insert the first nail from the distal medial entry point
• Direct it proximally across the fracture site
• Use fluoroscopy to confirm proper trajectory and reduction
• Insert the second nail from the distal lateral entry point
• The nails should form a stabilizing construct across the fracture

Step 5: Fracture Reduction

• Manipulate the fracture under fluoroscopic guidance
• Achieve anatomic alignment of the fracture fragments
• Confirm proper rotational alignment of the tibia

Step 6: Complete Nail Advancement

• Advance both nails fully across the fracture site into the proximal fragment
• Ensure adequate purchase in the proximal tibia
• Confirm that the nails are properly seated at their insertion points

Step 7: Final Assessment

• Obtain AP and lateral fluoroscopic images to confirm:
  • Proper fracture reduction
  • Appropriate nail position
  • Adequate stability of the construct
• Ensure restoration of normal tibial alignment and rotation

Step 8: Wound Closure and Post-operative Care

• Irrigate the wounds with sterile saline solution 1
• Close the wounds in layers
• Apply a sterile dressing
• Apply a posterior splint or cast for additional support

Post-operative Management

1. Maintain limb elevation for 24-48 hours
2. Begin early finger range of motion exercises 2
3. Initiate progressive weight-bearing protocol:
   • Non-weight bearing for 6-8 weeks
   • Partial weight bearing from 8-12 weeks
   • Full weight bearing after radiographic evidence of healing
4. Obtain follow-up radiographs at 3 weeks and at the end of immobilization 2
5. Monitor for signs of infection or fracture-related infection 1

Special Considerations

• Fracture Pattern: Ender nailing is most suitable for simple fracture patterns; avoid in highly comminuted fractures 3, 4
• Nail Configuration: For distal tibia fractures, use Method A configuration with nails inserted from distal to proximal 4
• Bone Quality: Consider patient's bone quality when selecting this technique
• Infection Prevention: Administer appropriate perioperative antibiotics 1
• Alternative Techniques: Consider other fixation methods if the fracture is highly unstable or comminuted

Potential Complications and Management

• Malunion: Ensure proper reduction and alignment during the procedure
• Delayed Union: Monitor healing progression with serial radiographs
• Hardware Irritation: May require nail removal after fracture healing
• Infection: Follow infection prevention protocols; consider NPWT for high-risk cases 1

Ender nailing has shown good union rates for tibial shaft fractures, with studies reporting successful union in 93-100% of cases 5. However, it should be avoided in comminuted fractures that might shorten around the nails 3.