A 42-year-old woman with type II open, right distal-third tibia, fibula fractures
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A 42-year-old woman was involved in a motorcycle crash and sustained a type II open, right distal-third tibia and fibula fractures (Figure 1).
The patient was appropriately resuscitated, given IV antibiotics, tetanus booster and cleared for surgery by the general surgery trauma team. The patient was neurovascularly intact with soft compartments. The wound was open medially approximately 2 cm with minimal contamination. Preoperative CT of the ankle did not reveal intra-articular extension into the tibial plafond.
Source: Eben A. Carroll, MD
The patient underwent debridement of the open fracture with intramedullary (IM) nail in the semi-extended position (suprapatellar IMN) (Figure 2). She was made weight-bearing as tolerated and discharged after an uneventful postoperative course.
Six weeks after the index procedure, she presented for routine follow-up and reported persistent pain at the fracture site exacerbated by weight-bearing. Her wounds demonstrated appropriate healing without concerning features of underlying infection. Her radiographs demonstrated varus collapse at the fracture site (Figure 3). She elected to undergo revision IMN to correct the varus deformity.
What is the best next step in management of this patient?
See answer below.
Revision IM nailing with blocking screw placement
For the revision surgery, an infrapatellar approach was used. After removing the interlocking screws proximally, the nail insertion jig was threaded to the proximal end of the nail.
The distal interlocking screws were removed, and the nail was backslapped to the level of the fracture. The fracture site was found to be mobile and was reduced via closed methods. Two blocking screws were placed in an anterior-to-posterior (A-P) trajectory in the lateral aspect of the distal tibia to force the nail out of the malaligned path. The nail was passed down into the distal fragment with the block screws creating a new lateral cortex in the metaphyseal bone. Anatomic alignment was confirmed on biplanar fluoroscopy. Three distal interlocking screws were placed, including one in the A-P trajectory (Figure 4). Lastly, two proximal interlocking screws were placed. The patient was made weight-bearing as tolerated in the postoperative setting (Figure 5).
Discussion
Distal-third tibia fractures (Orthopaedic Trauma Association classification type 43A) are challenging injuries to treat. IM nailing provides a more minimally invasive approach compared with traditional open reduction with locking plate fixation, while respecting the soft tissue of the distal leg and allowing for early weight-bearing and return to function. Rate of fracture union and time to union are similar between the two treatment types and appears to be more affected by other patient and injuries factors, such as smoking, degree of soft tissue damage and open fracture.
The relative indications for IM nailing have expanded to include more distal fractures as modern implants have evolved to include more multiplanar locking options. Concurrently, the use of IM nail fixation for distal tibia fractures has increased in popularity in the past 2 decades. Reduction of distal tibia fractures during IM nailing presents a technical challenge with reports of angular malalignment in up to 23% to 50% of cases. We present a patient who underwent IM nailing for a distal-third tibia fracture complicated by varus malunion in the early postoperative period. The patient subsequently underwent revision IM nailing with the use of blocking screws to maintain anatomic alignment.
Preoperative planning
For distal tibia fractures, a preoperative CT is often indicated to evaluate for intra-articular involvement, especially with spiral fracture patterns, in which plafond involvement has been demonstrated in up to 43% of cases. Optimal patient positioning is supine on a radiolucent table with an ipsilateral hip bump to prevent external rotation of the leg. With respect to surgical approach and nail insertion, the suprapatellar technique has recently been implemented with increasing frequency due to improved ability to manipulate the fracture and to minimize soft tissue damage, as well as the ease of switching between fluoroscopic views intraoperatively. For distal tibia fractures, suprapatellar nail insertion has demonstrated significantly lower rates of malalignment greater than or equal to 5° compared with infrapatellar insertion (3.8% vs. 26.1%). At our institution, suprapatellar nailing in the semiextended position is accomplished by placing bumps constructed of towels beneath the knee and distal tibia. The towels allow for customization of bump height as other tools obligate the knee to a given amount of flexion.
Reduction techniques
Obtaining and maintaining reduction of the fracture is critical during reaming. This can be facilitated using a combination of towel bumps under the leg, a mallet to counter the deforming force, manual traction or percutaneous clamping across the fracture site.
Certain fractures may be amenable to provisional plating with a 2.7-mm plate using multiple unicortical screws to temporarily hold reduction. This can be done through the wound in open fractures without a significant increase in periosteal stripping. For segmental fractures, this may be done for damage control purposes or to facilitate reduction of multiple fracture segments.
Guide wire/nail endpoint
Traditionally, IMN terminal position in the treatment of tibia fractures has been directed to be center-center on the talus on the anteroposterior (AP) and lateral views. More recently, however, this has come into question, as the center-center endpoint may worsen valgus malalignment. A slight lateral nail endpoint has shown improved coronal alignment and a 2.9% rate of malalignment greater than or equal to 5° vs. 27.5% with a more medial endpoint in the coronal plane. We recommend terminal guide wire and nail placement at the lateral-third and middle-third junction of the tibial plafond.
Distal locking screws help maintain the alignment once the nail is in place. The use of only one distal locking screw may result in nonunion in up to 80% of cases. The presence of distal screws alone does not eliminate risk of malalignment; caution should be used with screw trajectory. Cranial-medial to caudal-lateral trajectory may create an added valgus moment at the fracture while a caudal-medial to cranial-lateral trajectory may create a varus moment. Modern IMN designs allow for additional distal locking options in orthogonal planes. An A-P screw will provide added stability of the distal fragment and helps to avoid a windshield wiper effect in the coronal plane, which may result in varus or valgus malalignment. Use of multiplanar locking screws can be important in short segment fixation. Placement of an A-P screw at the distal tibia is linked with increased risk to the tibialis anterior tendon, extensor hallucis longus tendon and anterior tibial neurovascular bundle with at least one of these damaged in most cases reported in studies. An open or mini-open approach should be considered to protect soft tissue and neurovascular structures and ensure the A-P screw is flush with the bone.
Blocking screws
Blocking screws help reduce the effective metaphyseal space to maintain nail alignment. The number of screws needed depends on location of the fracture and the anatomical space available to place them. For distal tibial fractures, one or two screws may be sufficient. Traditionally, the recommended placement is on the concave side of the deformity with one screw proximal and one distal to the fracture site. Alternatively, the “reverse rule of thumb” is a quick reference to determine optimal blocking screw placement. This involves visualizing the deformity, envisioning manually correcting the deformity with both hands using thumbs (nearer to the fracture) and index fingers (farther from the fracture) and inserting the blocking screw on the opposite side of the nail from where the thumbs and index fingers are placed (Figure 6). Essentially, place blocking screws where you do not want the nail to go. In this case, blocking screws were placed laterally in the distal fragment to correct the deformity. Blocking screws may be used during the index surgery as needed and are important tools for revisions cases to correct the IMN trajectory to improve coronal alignment.
Distal-third tibia fractures are technically challenging to treat. Orthogonal distal interlocking screws can prevent the “windshield wiper” effect. However, care must be taken to avoid neurovascular injury. Blocking screws can aid in and maintain nail passage in the short distal segment of a fracture, especially during revision.
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- For more information:
- Nicholas A. Andring, MD, is an orthopedic resident; Eben A. Carroll, MD, is a professor of orthopedic surgery, trauma; T. David Luo, MD, is an orthopedic resident; and Mitchell T. Tingey, BS, is a medical student at Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center. They can be reached at Medical Center Blvd., Winston-Salem, NC 27157. Andring’s email: nandring@wakehealth.edu. Carroll’s email: ecarroll@wakehealth.edu. Luo’s email: tluo@wakehealth.edu. Tingey’s email: mtingey@wakehealth.edu.
- Edited by Steven D. Jones Jr., MD, and Donald (DJ) Scholten, MD, PhD. Jones is a chief resident in the department of orthopedic surgery at the University of Colorado. He will pursue a fellowship in sports medicine at Stanford University following residency completion. Scholten is a chief resident in the department of orthopedic surgery at Wake Forest University School of Medicine in Winston-Salem, North Carolina. He will be a sports medicine fellow at the University of Michigan following residency. For information on submitting Orthopedics Today Grand Rounds cases, please email: orthopedics@healio.com.
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