Subject: Distal Tibial Fx - Nail or Not
Date: Fri, 24 Jan 2003 12:30:27 +0100
From: Alo Kullerkann
I would like to discuss next case.
38 y/o male tvisted his leg on a slippery street.
Question arised when we started to plan operative treatment. My preference was IM nail plus 1-2 additional percutaneous screws as fracture goes deep down to the point where nail tip should be located. This plan was denied by my elder colleques as they they did not like to nail such a low fracture. So we plated this tibia with minimal soft tissue stripping. Comments are welcome.
Would You nail this tibia? If yes then would You use calcaneal traction or distractor? Would You use additional screws? Any other tips?
In my institution interlocking IM nails have been available for about 4 years. It is well known that indications widen equally to experience. Usually we nail fractures 5-7 cm from jointline.
What is your practice?
Thanks in advance,
Alo Kullerkann, MD.
Date: Fri, 24 Jan 2003 06:45:22 -0500
From: Benedetti Gary E LtCol 74 MDOS/SGOSO
Our elders are wise through experience. I think with care this fracture can be nailed using manual traction with the leg over a bolster. With experience I think you will find yourself nailing more and more distal fractures.
Gary E. Benedetti, LtCol, USAF, MC, FS
Orthopaedic Trauma Surgery
Date: Fri, 24 Jan 2003 09:05:10 -0700
From: John Ruth
The reduction you performed looks excellent. The fracture pattern is absolutely one that could be treated with an IM rod
Date: Fri, 24 Jan 2003 21:04:01 +0500
From: Alexander Chelnokov
AK> Question arised when we started to plan operative treatment. My preference was IM nail plus 1-2 additional percutaneous screws as fracture goes deep down to the point where nail tip should be
I would definitely nail it with preliminary traction by a small wire distractor. Even in cases of articular extension with Volkmann's triangle numerous nailings were performed successfully. For this case it seems to me additional perQ screws would be superfluous, using of all distal holes would be quite enough.
Alexander N. Chelnokov
Ural Scientific Institute of Traumatology and Orthopaedics
str.Bankovsky, 7. Ekaterinburg 620014 Russia
Date: Fri, 24 Jan 2003 12:59:49 -0600
Subject: Re: nail or not?
Your post op xrays look good.
I would use IMN w/ manual traction over a radiolucent triangle.
No interfrag screws and 2 distal transverse screws. The post comminution precludes AP locking and two transverse screws wee stronger in torsion than one transverse and one AP (McClauren OTA 2002)
William T Obremskey MD MPH
Date: Fri, 24 Jan 2003 15:18:31 -0500
From: James Carr
One trick I have used for "extreme" tibial nailing is to rotate the nail so the M-L locking screw catches the distal fibula. Blocking screws is another trick that helps stretch indications beyond intended usage.
Date: Fri, 24 Jan 2003 23:39:13 EST
Locked IM nailing can be perfomed here. If the distal interlocking screw holes are too proximal relative to the fracture, an old trick is to position the distal interlocking screws closer to the distal articular surface by cutting off the tip of the nail.
I have never had to do this as the nail we have (Synthes) have very distal holes. This was something I heard about or very rarely saw during my residency when there were fewer choices of nails and when, I think, the distal screw holes were relatively more proximal.
Arlington Orthopedics and Hand Surgery Specialists, Ltd.
1100 W. Central Road, Suite 304
Arlington Heights, Illinois 60005