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Nature of the Problem - Orthopaedic Trauma...
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1/31/2017 1 Proximal Tibia Shaft Fractures Chris Finkemeier MD, MBA Orthopedic Trauma Surgeons of Northern California Nature of the Problem
Transcript of Nature of the Problem - Orthopaedic Trauma...
1/31/2017
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Proximal Tibia Shaft Fractures
Chris Finkemeier MD, MBA
Orthopedic Trauma Surgeons
of Northern California
Nature of the Problem
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High rates of mal-alignment (with nails).
Lang CORR 1995- 58%
Freedman CORR 1995- 84%
Valgus
Pro-curvatum(apex anterior)
Off-axis entry leads todeformity
Valgus
Solution
Medial entry portal
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Muscular Forces Play a Secondary Role
Pro‐curvatum
Two reasons
Patella blocks on-axis entry1.
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Pro‐curvatum
Posteriorly directed nail insertion.
x
Patella blocks on-axis entry1.
Knee flexion
Pro‐curvatum
Posteriorly directed nail insertion.
x
SolutionPatella blocks on-axis entry1.
2.
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What about other methods?
External Fixation (fine wire fixators)
Plate Fixation
Lower rate of malunion with plates
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Proximal tibia fracture plating
Eliminates the deforming forces &takes the patella out of play
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Proximal tibia fracture plating
Potentially better fixation and maintenance of reduction
Serious consideration must be given before nailingproximal tibia fractures
Treatment Options
Nail
Plate
Infrapatellar
Suprapatellar
How are we going to counteract the deforming forces?
Usually requires “countermeasures”
May require “countermeasures”
May require “countermeasures”(relatively uncommon)
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Countermeasure?
an action taken to counteract a danger or threat.
Promimal Tibial Nailing Countermeasures:Tricks to avoid malunion
• Correct starting pointcentral & proximal
• Nail in extension
• “Joy sticks” or Shanz Pins
• Blocking screws
• Unicortical plating
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MedialLateral
Starting Point is Key
– Start High
– Medial side of LATERAL TIBIAL SPINE
McConnel et al. JOTTornetta et al. JOT
External Rotation 200
Journal of Orthopedic Trauma
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Proper Rotation
Lateral Tibia Plateau
should bisect fibula
Semi-extended Position
Medial parapateller arthrotomy
Tornetta, CORR, 1996
Nail in Extension
15-200 flexion
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Suprapatellar Nailing
Allows insertion ofnail closer to the axis oftibia
1. Nail in extension2. Improved nailing axis
Push/Pull Shanz Pins
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BLOCKING SCREWS
KRETTEK ET AL, JBJS-B 99’RICCI ET AL , JOT 01’
• Block passage of nailfrom unwanteddirection
• Screws placed on concave side of deformity.
• Functionally narrows IM canal
• Increase strength and rigidity of fixation
Unicortical Plate
Mathews et al., Orthopedics, 1997
Dunbar et al., JOT, 2005
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16 y/o male
MCC
Closed Fx
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Suprapatellar Nailing is my method of choice
+/-
Unicortical plate / blocking screws / shanz pins
If I choose to nail
Why?
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Three Reasons
1. Nailing in near extension decreases the deforming forceson the proximal tibia.
3. May decrease or possibly eliminate knee pain, especially while kneeling.
Allows simplified bi‐planar imaging.
Less manipulation of the leg decreases additional soft tissue damage and aids in maintaining reduction.
Facilitates use of clamps, distractors, fixators, blocking screws.
2. The injured leg does not need to be moved once the patient is positioned:
Nailing in “near extension” decreases deforming forces on the proximal tibia.
# 1
Tornetta, Paul. "Semiextended Position for Intramedullary Nailing of the Proximal Tibia." Clinical Orthopaedics & Related Research 328 (1996): 186. Print.
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Suprapatellar entry allows the nail to be insertedunder the patella in line with the tibia medullarycanal on the AP and lateral.
VS
The injured leg does not need to be moved once the patient is positioned
# 2
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VS
Facilitates bi‐planar imaging of entire tibia with minimal surgeon manipulation.
Suprapatellar Positioning
Infrapatellar Positioning
Infrapatellar Suprapatellar
VS
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Less manipulation of the leg decreases additional soft tissue damage and aids in maintaining reduction
Simplified maintenance of reduction and use of clamps distractors, fixators, Shanz pins, blocking screws , etc.
InfrapatellarSuprapatellar
VS
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Maintenance of reduction and use of clampsdistractors, fixators, Shanz pins, blocking screws , etc is easier.
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May decrease or possibly eliminate knee pain, especially while kneeling
#3
Suprapatellar nailing utilizes an incision proximal to the patella
ShouldEliminate injury to the infrapatellar branch of the saphenous nerve.Avoid injury to the patellar tendon and paratenon.Eliminate incisional scaring directly over the anterior to the knee.Reduce fat pad scaring ?
VS The Ciba CollectionOf Medical IllustrationsVol 8, Part 1Musculoskeletal SystemCiba-Geigy Corporation1987
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How I do it
Leg is positioned with 20-300 of Knee flexion.
Vertical Midline skin incision 1-2 finger breadths proximal to patella.
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Midline quadriceps tendon split.
If the knee is tight:extend incision intothe proximal portionof a medial parapatellarapproach.
Passage of nailing instruments under the patella through protective cannulas.
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16 y/o male
MCC
Closed Fx
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Restore length
Ex Fix
Or
Distractor
For Proximal Fractures
consider placing ex-fix
pin in distal femur.
Keeps proximal segmentmobile for fine tuningreduction
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Restore Alignment
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Proper entry point Nail parallel to anterior cortex
6 months
No complaintsor problems
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Sometimes it’s just not that simple
Blocking Screws
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Blocking screws
Unicortical Plate
Mathews et al., Orthopedics, 1997
Dunbar et al., JOT, 2005
“Simple”Usually controls both displacementsTake advantage of open fracture wounds
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Unicortical Plate and blocking screws
When things get really tough
My preference
Leave the blocking screws and plates in placeafter nailing.
Should the countermeasures be removed after nailing?
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Summary
Extra-articular Tibia Fractures are challenging and can beeasily mal-aligned
Intramedullary nailing is technically difficult.
IMN frequently requires adjunctive reduction techniques (countermeasures) to obtain and maintain reduction.
Plating is an excellent option for proximal fractures
Minimally invasive techniques are ideal, but not if poor reduction.
Direct reduction through open approaches are necessary at times, but should be done carefully without excessive damage to the soft tissues.
