Procedure for Tibial Fracture Management Using Ender's Nailing
Ender's nailing is a viable technique for tibial fracture fixation, particularly for open fractures (grade I and II), but should not be used for comminuted fractures that might shorten around the nails. 1
Preoperative Assessment and Planning
- Evaluate fracture pattern and stability using radiographic imaging
- Assess for comorbidities that may affect surgical outcomes
- Review patient's functional status and mobility
- Check metabolic status and skin condition at surgical site
- Differentiate between pathologic and traumatic fractures
Anesthesia Considerations
- Either spinal/regional or general anesthesia can be used
- Regional anesthesia may reduce postoperative confusion 2
- Consider multimodal analgesia strategy:
- Paracetamol
- NSAIDs (if not contraindicated)
- Low concentration local anesthetic for peripheral nerve blocks without adjuncts 2
- Avoid opioids as sole analgesic due to risk of respiratory depression
Surgical Procedure Steps
1. Patient Positioning and Preparation
- Position patient supine on a fracture table
- Apply appropriate traction to achieve fracture reduction
- Prepare and drape the entire lower extremity using sterile technique
- Confirm reduction under fluoroscopic guidance
2. Entry Point Selection
- Identify entry points at the medial and lateral malleoli
- Make small incisions (1-2 cm) at these points
- Protect neurovascular structures during approach
3. Canal Preparation
- Create entry holes at the malleoli using an awl
- No reaming is typically required with Ender nails
- Ensure proper trajectory for nail insertion
4. Nail Selection and Insertion
- Select appropriate length Ender nails (typically 3-5 mm diameter)
- Insert first nail from medial malleolus entry point
- Advance nail across fracture site under fluoroscopic guidance
- Insert second nail from lateral malleolus
- Additional nails may be inserted as needed for rotational stability
5. Fracture Reduction and Nail Advancement
- Manipulate fracture fragments as needed during nail advancement
- Ensure proper alignment in both AP and lateral planes
- Confirm reduction and nail position with fluoroscopy
- Advance nails proximally into metaphyseal bone
6. Final Positioning and Stability Assessment
- Ensure nails are properly seated
- Verify fracture reduction and alignment
- Test stability of the construct
- Cut or bend nail ends at entry points to prevent soft tissue irritation
7. Wound Closure
- Irrigate wounds thoroughly
- Close entry point incisions
- Apply sterile dressing
Postoperative Management
- Initiate early mobilization to reduce complications
- Implement appropriate pain management protocol
- Begin weight-bearing as tolerated in most cases
- Monitor for complications including:
Follow-up Protocol
- Radiographic evaluation at 6 weeks, 3 months, 6 months, and 1 year
- Assess fracture healing, implant position, and potential complications
- Expected union time approximately 26.4 weeks 3
- Remove hardware if symptomatic after complete healing
Special Considerations
- For severely shortened or displaced fractures, external fixator-assisted closed nailing may be required 4
- Ender nailing should not be used for comminuted fractures that might shorten around the nails 1
- For open fractures, thorough debridement and antibiotic therapy are essential before nailing
Advantages of Ender's Nailing
- Less invasive than plate fixation
- Lower infection rates compared to external fixation (9.1% vs 13.8%) 3
- Faster union times (26.4 weeks vs 30.2 weeks with external fixation) 3
- Lower malunion rates compared to external fixation (5.8% vs 15.7%) 3
- Fewer secondary procedures required compared to external fixation 3
Ender's nailing represents a viable alternative to external fixation for appropriate tibial fractures, particularly for grade I and II open fractures, with comparable or better outcomes in terms of union time, alignment, and complication rates.