What is the step-by-step procedure for treating a fracture shaft tibia with intramedullary (IM) nailing?

Step-by-Step Procedure for Intramedullary Nailing of Tibial Shaft Fractures

Intramedullary nailing is the most effective surgical approach for treating tibial shaft fractures, providing excellent stability while minimizing soft tissue disruption, allowing for earlier weight-bearing and improved functional outcomes. 1

Preoperative Considerations

• Assess fracture pattern, location, and presence of comminution through appropriate imaging to determine optimal nail length and diameter 2
• Evaluate for associated injuries, especially in cases of high-energy trauma 2
• In patients with severe associated injuries (brain, thorax, abdomen, pelvis), circulatory shock, or respiratory failure, consider temporary external fixation followed by delayed definitive intramedullary nailing once the patient is stabilized 2
• For isolated tibial shaft fractures without severe associated injuries, early definitive osteosynthesis within the first 24 hours is recommended to reduce local and systemic complications 2

Patient Positioning and Setup

• Position patient supine on a radiolucent operating table 1
• Place a bump under the ipsilateral hip to facilitate access to the entry point 1
• Prepare and drape the entire limb to allow for intraoperative manipulation 1
• Ensure C-arm positioning for obtaining both anteroposterior and lateral views of the tibia 1

Surgical Approach

Entry Point Creation

• Make a 4-6 cm longitudinal incision 2-4 cm proximal to the superior pole of the patella for a suprapatellar approach 1
• Split the quadriceps tendon longitudinally at its midline 1
• Insert a cannula device with blunt trocar and protective sleeve into the knee joint between the patella and femoral trochlea 1
• Place a 3.2-mm guide pin at the junction of the articular surface and anterior cortex of the tibia, in line with the intramedullary canal 1
• Advance the guide pin 8-10 cm into the proximal tibia 1
• Remove the inner centering sleeve and use a cannulated entry drill over the pin to ream down to the metadiaphyseal level of the proximal tibia 1

Fracture Reduction

• Achieve and maintain fracture reduction using one of the following techniques:
  • Manual traction and manipulation 3
  • Temporary external fixator 4
  • Provisional plating through the open wound (particularly useful in open fractures) 5
  • Reduction clamps or percutaneous reduction tools 6

Reaming and Nail Insertion

• Pass a ball-tipped guidewire centrally across the reduced fracture down to the level of the distal tibial physeal scar 1
• Confirm proper guidewire position with fluoroscopy in both AP and lateral views 1
• Perform incremental reaming, typically starting at 8mm and increasing by 0.5mm increments 3
• Ream 1-1.5mm larger than the intended nail diameter 3
• Select appropriate nail length and diameter based on preoperative planning and intraoperative assessment 3
• Insert the nail over the guidewire down the tibial canal 1
• Confirm appropriate nail position radiographically, ensuring the nail is seated properly at the entry point and extends to the appropriate distal level 1

Interlocking Screw Placement

• Place distal interlocking screws using a freehand technique under fluoroscopic guidance 1
• Attach the proximal aiming arm to the insertion handle 1
• Drill, measure, and place interlocking screws into the proximal tibia 1
• Verify final position and alignment with fluoroscopy 1

Wound Closure

• Close the quadriceps tendon with absorbable sutures 1
• Close subcutaneous tissue and skin in standard fashion 1

Postoperative Management

• Early mobilization and range of motion exercises are encouraged 3
• Weight-bearing status depends on fracture pattern, stability of fixation, and associated injuries 3
• For stable fractures with good fixation, early weight-bearing can be initiated 3
• Regular follow-up with radiographic assessment to monitor fracture healing 3

Special Considerations

• For distal tibial fractures, additional techniques may be needed to ensure proper alignment and fixation, including blocking screws or fibular fixation 6
• In open fractures, thorough irrigation and debridement should be performed prior to definitive nailing 5
• For severely comminuted fractures or those with bone loss, consider staged procedures with temporary external fixation followed by definitive nailing once soft tissues have recovered 2, 4

Potential Complications

• Malalignment (especially valgus/procurvatum in proximal fractures or varus in distal fractures) 6
• Compartment syndrome 3
• Infection (higher risk in open fractures) 4
• Nonunion or delayed union 3
• Hardware failure 3

By following this systematic approach to intramedullary nailing of tibial shaft fractures, surgeons can achieve reliable fracture reduction and stable fixation, promoting early mobilization and optimal functional outcomes.