Intramedullary Nail for Open Tibial Fracture
Main Text
Table of Contents
The tibia is particularly susceptible to open fractures because of its subcutaneous location. The status of the overlying soft tissue is regarded as the key determinant of fracture management strategy. Intramedullary nailing is widely recognized by the orthopedic community as the treatment of choice for most displaced, open, tibia shaft fractures due to the extent of soft tissue damage and the risk of infection. Both open and closed fractures are amenable to nailing. Occasionally, plates and external fixators are required to manage certain tibial fractures.
This article describes the stabilization of an open tibia shaft fracture using an intramedullary nail. After copious irrigation and debridement of the fracture site, a transpatellar tendon split is used to expose the nail entry point. This is followed by fracture reduction, sequential reaming, and nail insertion and locking. Finally, the technique for proximal tibia traction pin insertion is demonstrated on the contralateral tibia.
Tibial fracture; intramedullary nail; open fracture; internal fixation.
Fractures of the tibial diaphysis can occur across the age spectrum and can present as the result of a variety of accidents. They range from high-energy, comminuted fractures often in younger patients to spiral fractures commonly seen in older patients from lower energy mechanisms. Tibia shaft fractures are commonly treated by both intramedullary (IM) nails as well as a screw and plate construct. Both methods have been shown to be effective and have a low risk of infection.1-4 Many times when the fracture is open, often in a younger patient from a high energy mechanism, an IM nail is preferred as it is less traumatic to the surrounding soft tissues.1 Here we describe the indications and methods for IM nail use in an open tibia shaft fracture.
These injuries are often the result of high-energy mechanisms, with motor vehicle collisions and sports accidents making up about 60% of cases and falls or assaults accounting for another 20% in one study.5 A full history should be obtained with details surrounding the event. Examples of relevant details could be if this patient was the driver or passenger, if restraints were worn, if airbags deployed, if there was a loss of consciousness, or if the patient had ever had any previous injuries or surgeries to the affected leg. All of these items can help guide the secondary exam and could have an effect on surgical planning. It is also important to evaluate the patient’s mental capacity and ensure injury or intoxication is not going to affect their ability to give informed consent.
Primary Exam:
It is important not to allow an open fracture to distract from a complete physical exam. Once the fracture site is evaluated, it should be cleaned of gross debris and contamination and washed with sterile saline. The attempted reduction should be done to try to keep the exposed bone covered with soft tissue and pressure of the skin in an effort to avoid skin necrosis. A neurovascular exam should be obtained, especially distal to the fracture site. If needed, a Doppler ultrasound can be used to determine if perfusion is intact distally. Any concern of disruption should prompt immediate vascular surgery consultation and a CT angiography to ensure vascular patency. It should be noted that on some occasions, reduction of a severely displaced fracture can allow for the return of perfusion in instances where there are no palpable pulses distally. Evaluation of sensation and motor functioning can help determine the extent of soft tissue damage prior to entering the operating room to help manage operative planning and postoperative expectations.
Secondary Exam:
Because these are often a result of high-energy traumas, there are frequently concomitant injuries present in these patients. A thorough secondary exam is of vital importance to help prioritize care. In some instances, damage control orthopedic (DCO) care will need to be utilized. This might involve placing external fixation or skeletal traction temporarily while other injuries are addressed. It is also important to frequently check compartments on these patients as injuries of the tibia can result in compartment syndrome of the leg, even in open fractures.
Plain films are often used to characterize the location of the fracture and the fracture pattern. Images of the knee and the ankle should also be obtained in order to rule out any injury to the adjacent joints.
A fracture is described as “open” when there is a violation of the overlying skin. These injuries necessitate a trip to the operating room as there is a need for intraoperative irrigation and debridement, in which sterile saline is run into the wound to clean it out of any debris, and dead or devitalized tissue is removed. Using a construct from plate and screws is possible and favored by some, but IM nails are generally preferred in these instances as they allow for immediate weight-bearing and reduce soft tissue violation.1,2 It has been demonstrated, however, that there is a greater risk for malalignment with an infrapatellar nail than with a suprapatellar nail or a plate and screw construct.1
Indications for IM tibial nailing are the following: tibial shaft fractures, proximal and distal tibia fractures, open fractures, polytrauma patients. The goal of using an IM tibial nail is to achieve a reduction of the fracture site and provide a way to maintain that reduction postoperatively. IM nails also allow patients to immediately put weight on their extremities and allows for the earlier return of function, and decreased risk of complications, such as blood clots.6 Additionally, IM nails of the tibia have been found to have shorter operative times and are easier to remove.3 The disability score between nailing and plating at six months has been shown to be no different.7
As mentioned previously, in some instances of polytrauma, DCO is needed. This may alter the typical course of care that the patient would otherwise have received.
Contraindications for intramedullary nailing include the following: open epiphyses, small medullary canal, deformity (eg. prior malunion), grossly contaminated open or infected fractures, fracture in line of locking screws, an associated femoral neck fracture.
If the medullary canal is deformed prior fracture or due to developmental abnormality nailing may not be possible.
Reaming during intramedullary nailing in high trauma patients carries several risks. If severe bacterial contamination or infection are present, nailing may spread infection through the medullary canal, and should be avoided. External fixator pins are a common source of contamination. If such pins appear to be infected, or have been present for more than 2–3 weeks, preliminary pin removal, debridement, and antibiotics may be advisable before nailing. Also it can increase the risk of infection, particularly in open fractures, due to the disruption of the medullary blood supply and potential contamination.13 The process of reaming leads to bone overheating which may result in thermal osteonecrosis. Reaming results in increased intramedullary pressure and secondary embolization of marrow elements to the pulmonary system leading to pulmonary embolism. Intramedullary nailing in severe trauma may cause respiratory distress.14,15
Reaming can be considered reasonably safe under the following conditions: the patient is hemodynamically stable, the fracture is closed (thereby reducing the risk of contamination), appropriate aseptic techniques are employed, and the surgical team is experienced.
The frequency of tibial nonunion after intramedullary nailing ranged from 3% to 48%.12 Active smoking, a residual interfragmentary gap > 5 mm, and an initial open wound are risk factors for postoperative complications after intramedullary nailing.11 Other risk factors include fracture type (eg. pathological fractures, such as metastatic bone disease), pre-existing conditions (eg. diabetes melitus), higher TFI ration (the ratio of fracture site diameter to tibial isthmus diameter), and age.
Complications of intramedullary reaming include deep wound infection, malalignment, intraoperative fractures, non-union, malunion, delayed union.16 Knee pain is the most common complication after intramedullary nailing which occurs during the patellar tendon splitting and paratenon approach.17
The proximal tibia is triangular, with a broad metaphyseal region narrowing distally. The tibial shaft articulates with the talus, fibula, and distal femur. Key arteries include the anterior tibial artery, which becomes the dorsalis pedis, and the posterior tibial artery, ending as the medial and lateral plantar arteries. The peroneal artery terminates as the calcaneal arteries.
Nerve supply is critical: the tibial nerve innervates the posterior compartments, while the common peroneal nerve splits into superficial and deep branches, serving the lateral and anterior compartments. The saphenous nerve innervates the medial foot and leg.
Muscles include the popliteus, tibialis posterior, flexor digitorum longus, and flexor hallucis longus in the deep compartment; gastrocnemius, soleus, and plantaris in the superficial posterior compartment; peroneus longus and brevis in the lateral compartment; and tibialis anterior, extensor digitorum longus, extensor hallucis longus, and peroneus tertius in the anterior compartment.17
Once the patient is in the operating room, it is necessary to further open the wound and debride the fracture site and surrounding soft tissues. The incision should be big enough to expose the zone of injury. Once exposed, use a curette to debride necrotic tissue, and irrigate with 3–12 L of normal saline. After irrigation is complete, move on to obtaining the reduction of the fracture. It is crucial to emphasize that after wound irrigation, re-draping and changing equipment are essential steps to maintain asepsis. These practices significantly reduce the risk of postoperative infections by preventing the introduction of contaminants into the surgical site.18,19
A triangle can be used to help position the leg in a manner most conducive to obtaining and maintaining reduction while still being able to use intraoperative fluoroscopy. The knee is kept in a flexed position in order to gain access to the proximal tibia where the nail will be inserted.
Mark out the opening incision with a marking pen. The incision for a transpatellar tendon approach is made using the anatomic landmarks of the inferior pole of the patella and the tibial tuberosity. The incision can be made in two passes, with a more superficial incision through the skin followed by a more aggressive deep incision to the level of the tibia. Care should be taken to only violate the tendon in the direction parallel with its fibers to facilitate closure and minimize tendon damage.
Following the opening incision, use a guidewire freehand to gain entry into the IM canal of the tibia. This should be started as far posterior as possible while still staying anterior to the articular portion of the plateau. It should be placed along the anatomic axis of the tibia and tapped into place using a mallet. In this approach, the desired starting point is just anterior to the articular surface of the tibial plateau and just medial to the lateral tibial spine on an AP knee view, with the entry wire parallel to the anterior tibial cortex to neutralize the anterior vector.18,19 The position should be checked with fluoroscopy in order to verify starting point and trajectory before advancing the guidewire.
Once it is verified in both anteroposterior and lateral views that the starting point and trajectory are acceptable, use a power wire driver to advance the wire. It is crucial to confirm that on fluoroscopic images the level of the ankle joint, the ball-tipped guide wire is well-centered both on the anteroposterior as well as the lateral view.18,19 Once the wire is in the desired position within the canal, use the opening reamer to clear cortical bone from the path of the nail. Take care to fully seat the tissue protector against the cortical bone to spare iatrogenic damage to the articular cartilage and the surrounding soft tissues.
Next remove the opening reamer, tissue protector, and wire and insert a ball-tipped guide wire to the level of the fracture. Use fluoroscopy to ensure the wire stays within the IM canal and does not exit through the fracture site. A small bend can be placed on the wire below the ball in order to help in directing the wire to the desired location. A T-handle chuck and mallet can be used to help drive in the wire if needed. The wire should be driven distally within the canal as centrally as possible to a point just proximal to the physeal scar above the plafond.
A ruler is then used over the wire in order to determine the length of the nail that is needed. The ruler should be seated all the way down on the cortical bone. Once the length of the nail is determined, reaming of the canal is needed. This allows for a better fit of the nail that fills the canal and provides better internal support. The smallest reamer should be placed over the guidewire and seated on the cortical bone before being attached to the power driver. A wire pusher should be used when backing the reamer out to maintain the wire’s position within the IM canal. Flexible reamers can be used if needed. When removing the reamer, it should be stopped within the canal proximally and removed by hand in order to protect the soft tissues. Reaming should be increased incrementally until chatter is observed at the diaphyseal isthmus.
Once the nail diameter is determined, it can be placed over the guidewire and into the IM canal. A strike pad attached to the nail can be used to allow for malleting the nail into place.
Once the nail is determined to be in the desired location using fluoroscopy, the targeting jig can be affixed, which will allow guidance in placing the interlock screws. A triple sleeve can be used in the jig to determine the entry point in the skin, and then an incision can be made with a skin knife. A Kelly clamp or hemostat can be used in the incision to clear away soft tissue from the screw path. Once done, the triple sleeve can be placed back in the jig and seated against the cortical bone. The middle piece of the triple sleeve is then removed and a drill is used to drill through both cortices. The depth can be measured off the drill depth guide or by hand, and the appropriate length screw should be introduced to lock the nail. This should be done for the available interlock screw positions. An acorn driver should then be used to remove the handle of the nail once the interlocks have been placed. The proximal interlocking screws can be used to fix the nail in the proximal bone, while the distal tibial fragment can be manipulated to obtain desired fracture reduction.
Considering the use of femoral distractor, reductions tools, percutaneous clamping, blocking screws, and supplemental plate fixation to aid in reduction and fixation. These can be combined to optimize outcomes.18,19 Common tools to obtain reduction are the point of reduction clamps, axial traction, and rotation. Once this is done, the distal interlock screws should be placed to maintain the reduction. The distal interlock screws are placed using the perfect circles technique.
To minimize the risk of common peroneal nerve palsy during the placement of proximal medial-to-lateral oblique interlocking screws, surgeons should use fluoroscopic guidance with the image intensifier angled perpendicular to the drill bit. The thin cortical bone of the proximal tibia and the close proximity of the fibular head can obscure tactile feedback, making it difficult to detect far cortex penetration. Screw length should be confirmed with a depth gauge, and lengths over 60 mm should raise suspicion for posterolateral prominence, risking nerve injury. For distal anterior-to-posterior interlocking screws, careful placement of the surgical incision and soft tissue dissection is crucial to protect the anterior neurovascular bundle, anterior tibial tendon, and extensor hallucis longus.18,19
Once all interlocking screws are placed, leg lengths should be checked to ensure symmetry and rotation are appropriate. Final X-rays should be obtained to ensure reduction has held and all implants are in their desired locations.
Following confirmation that all implants are in place and reduction has been achieved, the wounds can be irrigated and closed. Deep closure can be done with Vicryl as demonstrated here. Care should be taken in closing the patellar tendon. Nylons or staples can be used to close the skin.
The patient is able to immediately bear weight following tibial IM nail placement. Nylons or staples should be removed two weeks postoperatively.
Tibial shaft fractures often occur in the setting of high-energy trauma and can have concomitant injuries, often requiring damage control orthopedics and staged procedures.8,9 Because of the scant amount of tissue covering the anterior tibia, these can often present as open fractures. Long bone fracture management is a crucial aspect to stabilizing a patient and internal stabilization using an IM nail within the tibia is an excellent option for definitive fixation following tibial shaft fracture as it allows for immediate weight-bearing as well as necessitates minimal soft tissue disruption.8 Each patient should be evaluated on a case-by-case basis to prioritize the order and manner in which the injuries should be addressed. Generally, the outcomes are favorable for these procedures. The SPRINT trial investigated prognostic factors that can help stratify outcomes for patients preoperatively. These factors are high energy trauma, a fracture gap, full weight-bearing postoperatively, use of a stainless steel implant (as compared to titanium), and open fractures with the reamed insertion of an implant. However, reaming was found to be of benefit to closed fractures. Additionally, open fractures that were able to be closed and required no additional soft tissue procedures were not found to be statistically different for adverse outcomes.9 This procedure is common to orthopedic surgery as the tibia is the most frequently fractures long bone in the body and is generally well tolerated with good outcomes. This has been an overview of the indications, common presentations, and operative details for placement of a tibial IM nail using a transpatellar tendon split approach in the setting of an open tibial shaft fracture.
- Ball-tipped guidewire
- Portable fluoroscopy system
- Flexible reamers
- Tibial nails
- Interlocking screws
Nothing to disclose.
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
Citations
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- Vallier HA. Current evidence: plate versus intramedullary nail for fixation of distal tibia fractures in 2016. J Ortho Trauma. 2016;30:S2-S6. doi:10.1097/BOT.0000000000000692.
- Guo JJ, Tang N, Yang HL, et al. A prospective, randomized trial comparing closed intramedullary nailing with percutaneous plating in the treatment of distal metaphyseal fractures of the tibia. J Bone Joint Surg Br. 2010;92:984–988. doi:10.1302/0301-620X.92B7.22959.
- Gardner MJ. In displaced distal tibial fractures, intramedullary nail and locking plate fixation did not differ in terms of 6-month disability, J Bone Joint Surg. 2018;100(16):1435. doi:10.2106/JBJS.18.00635
- Märdian S, Schwabe P, Schaser KD. Tibiaschaftfrakturen [Fractures of the tibial shaft]. Z Orthop Unfall. 2015;153(1):99-119. https://doi.org/10.1055/s-0033-1358089.
- Laigle M, Rony L, Pinet R, Lancigu R, Steiger V, Hubert L. Enclouage centromedullaire des fractures ouvertes de jambes chez l’adulte. À propos de 85 cas. Revue de Chirurgie Orthopédique et Traumatologique. 2019;105(5):649-653. Available from: https://soo.com.fr/download/media/d08/d59/07-rony-louis.pdf.
- Costa ML, Achten J, Griffin J, et al. Effect of locking plate fixation vs intramedullary nail fixation on 6-month disability among adults with displaced fracture of the distal tibia: the UK FixDT randomized clinical trial. JAMA. 2017;318(18):1767-1776. doi:10.1001/jama.2017.16429.
- Metcalf KB, Brown CC, Barksdale EM 3rd, Wetzel RJ, Sontich JK, Ochenjele G. Clinical outcomes after intramedullary nailing of intraarticular distal tibial fractures: a retrospective review. J Am Acad Orthop Surg Glob Res Rev. 2020;4(6):20.0008. doi:10.5435/JAAOSGlobal-D-20-00088.
- Schemitsch EH, Bhandari M, Guyatt G, et al. Prognostic factors for predicting outcomes after intramedullary nailing of the tibia. J Bone Joint Surg Am. 2012;94(19):1786-1793. doi:10.2106/JBJS.J.01418.
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- Bauwens PH, Malatray M, Fournier G, Rongieras F, Bertani A. Risk factors for complications after primary intramedullary nailing to treat tibial shaft fractures: a cohort study of 184 consecutive patients. Orthop Traumatol Surg Res. 2021;107(3):102877. doi:10.1016/j.otsr.2021.102877.
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- AO Foundation Surgery Reference. Intramedullary nailing. Available at: https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/tibial-shaft/simple-fracture-spiral/intramedullary-nailing. Accessed October 6, 2024.
- Finelli CA, dos Reis FB, Fernandes HA, et al. Intramedullary reaming modality for management of postoperative long bone infection: a prospective randomized controlled trial in 44 patients. Patient Saf Surg. 2019(13):39 doi:10.1186/s13037-019-0215-3.
- Bedi A, Karunakar MA. Physiologic effects of intramedullary reaming. Instr Course Lect. 2006;55:359-66.
- Ghouri SI, Mustafa F, Kanbar A, et al. Management of traumatic femur fractures: a focus on the time to intramedullary nailing and clinical outcomes. Diagnostics. 2023; 13(6):1147. doi:10.3390/diagnostics13061147.
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Cite this article
Gottlich CP, Weaver MJ. Intramedullary nail for open tibial fracture. J Med Insight. 2024;2024(33). doi:10.24296/jomi/33.
Procedure Outline
Table of Contents
- Close Femoral Incisions and Debride Tibial Fracture
- Locate Entry Point for Tibial Nail
- Insert Guide Wire
- Ream Tibia
- Place Traction Pin
- Closing
Transcription
CHAPTER 1
Can't do a tibial on the outside. Pick ups, please. Yeah. Yeah. Scissors, please. He asked for scissors. I don't wanna use those 'cause they've been in that one. I wanna use fresh stuff over here, okay? Whatever. Can we have a 2-0? And I'll use a stapler here, I think. Staple. Yeah. We're gonna use nylon for that traumatic wound and for the distal inner locks. Yep, knee brace. Is he okay? Yeah. Can I get a pair of scissors? Are these mine? Yeah. So if someone asks you how big an incision you make, you say it exposes zone of injury. Variability issues with this though. Some people would call this a very, it's really not that common. It's a small thing. It's clearly high energy, but... How aggressive are you about taking out devitalized bone? If it's really devitalized, I'll take it out. But you know, if there's any articular attachment or something like that, I'll leave it. You know, if it's a low grade open and it's a very large piece. Do you always vac open wounds, or..? Not always. But in someone like this, who's really had a lot of injury, they're gonna be in the unit, they're coming back to the operating room, she's gonna be catabolic. I like to seal it up. Do you have another 2-0? Yeah. I know there's stuff here, I just don't wanna be holding a needle. A little challenging to get this one reduced perfectly, but we're gonna try our hardest. Mm-kay. Can we have a blue towel, please? That looks like it's pretty well reduced there. There, let's see a suck in there. All right. All right. Triangle. Yep. So another 30 minutes? No. 45. We're half done. That was about an hour, we got another hour.
All right, get the blue. Blue marker, please. Yeah. You just wanted to move that, didn't you? Just a little bit. Here, you wanna really be center, really center. All right, 10? And I'm pretty bold here. You're going down, right? Here, the other way. There you go, 'cause you wanna go down. You can do it in two passes. So make the skin first. Yep, there you go. And now, 'cause you don't wanna saw the skin. But you wanna go down, so it's like that way. Yeah, it's down on... What do you think about the different... I'm gonna make that. I like suprapatellar nailing. I do that for proximal and distal fractures. Good. Guys, do you have that? Now can just take this and put it in there. Like that. Let's see, maybe I can... Just push in, like that. This one a little bit. Oh, sorry. You want the knee flexed. You wanna get as far pushed here as you can, and then in line, so you're right between my fingers there. Yep. Tap, tap, tap. So, you just basically feel this in the middle, right? Yep. Keep going. Good. That's good. And then do you aim a little posterior or just? Just a tiny bit posterior. That looks pretty good.
I'm thinking maybe a little lateral, if anything, but we'll get an x-ray and see. How much have we done? Two. Yeah, we want three for the end. Three for the end. Do you have any preference for transpatellar, lateral... No real difference in knee pain, so I just go straight through, and it's easier. You can make a smaller incision, it's all faster. But why would you go lateral? Or medial. Some people do a medial parapatellar. Just enough to... I think, theocratically to avoid disrupting the patellar tendon. Data shows they're different, so... Repeat in the same hole and it's not gonna give it you you, that's fine. X-ray? Yep, that's fine. See, just make sure you're aiming more medial. A lot more medial. There you go. X-ray? Yeah. There. Just but really careful. You've got a camera on your head, so you gotta go around careful. Yep, that's fine. Yep. Yep. X-ray? Good. X-ray there. Save that. So that's your ideal starting point. That looks really nice. All right, let's come around to our lateral. X-ray there. So that's ideal. Save that. So that's your ideal starting point. That's really nice. Good job. So you're right on the corner, right in front of the articular surface, and you're just on the medial side of the lateral tibial spine. Okay? So that's perfect. All right, so let's open this up. X-ray there. I kind of find it's nice if you drive that down a little bit. The wire's really stiff, and so it kinda finds the canal, and it's gonna make you be a little bit more in line with where you wanna go. Okay. We'll put it on as soon as we go to a different view. Just don't hurt the skin. I'm trying to go towards you. Good. There you go. And then just right in the bone. Just brah. Brah. Just do it. Just go. Just run it into the bone. Go. Push. Then come out. Good. There you go. Like a trauma surgeon. All right. Lots of good work. Do you mind grabbing the light and pushing it down so this comes down a little bit. There you go, perfect. That's perfect. Watch your top, watch your top. Yeah. Good. Oh, whoa. Come down to the fracture, please. Good. X-ray there. Come down a little bit further. Yeah, this is pretty broken. But it's not really stripped. I don't know, two, three A. X-ray. All right, advance that. X-ray there. It's on something there. Watch out. Something there. X-ray there. Shot. Good. X-ray. Come distal, please. X-ray there. X-ray. Mm-kay. X-ray there. X-ray there. We gotta get this out and put a little curve on it, 'cause you're aiming a little bit medial there. So take this out. Look at their ankle. Is that normal? That's me twisting the foot 90 degrees. Do you have a... Do you have the bender? That'll do it. So, no, it's not normal. Look at that tilt there. I'm good. I'm good. Yeah, I don't put a lot of bend in it, just a subtle bend. Just enough to get it to go where you want. You end up getting a malalignment when you put your nail down. Tends to go into varus. X-ray. X-ray. More valgus. X-ray. That's out. That's out, so pull back. X-ray. Try again. X-ray? X-ray. That looks better. Keep going. Good. X-ray. So - get a T-handle on it so you can power it through there. That centered real nice though, I like that. X-ray there. Mallet. Here you go. Tap, tap, tap. Good. X-ray. So now turn it so it's going a little more anterior. X-ray there. So now you gotta turn it a 180. So you gotta, no, no, now you go to 90. X-ray. Now it's, x-ray. There you go. X-ray. There you go. Tap, tap, tap. X-ray. X-ray there. Good. Tap, tap, tap. Just a little bit. Good. X-ray there. So that looks good there. It's aiming right where I want it to. X-ray there. And now you gotta get it over the other way. So 180. There you go. X-ray. Good. So now tap, tap, tap. Yep. Like you mean it. Good. X-ray. See, that's starting to go the right way. And then let's check this way. X-ray. That looks good there. X-ray there. All right. Tap, tap, tap. Like you mean it. X-ray. A little bit more. X-ray. And now hit it like you mean it. You really want it down? Yep. X-ray. All right, I think that's probably okay. You can get it further, but I think it's okay. All right. X-ray there. X-ray. All right, so a little posterior, but I think that's okay. So now what? Come up to the knee, please. What do you need now? Bigger hands. But what equipment do you want next? Now a ruler. A ruler, please. Yep. Ruler? Here's the mallet back. So she's got a pretty small canal. So we're expecting a pretty small nail. Probably about a nine. So we start by measuring so we know the length. And then as you ream, that determines your diameter. X-ray there. Oh, that way. Yep. X-ray there. X-ray. Now you can just measure it. So that says, so what do you want? So they don't come in 320s. Oh, they don't. So 300s plus 15s for a tibia. So this'll be a 315. 315. Yeah. So 315. All right, and then we'll take an A5 and see what happens. Now if we can get to 10, it would be great, but since we put a nine in the femur it's hard to believe we're gonna get to it. Can you find out what nails we have? This is a, what do we say, 315 by eight and 315 by nine are our options that we're gonna use. Have the drill? So I want you to engage that on there first. Can we check and see if we have the tibial set on the - 315 by eight and 315 by nine. Yeah, if you could bring those both in. Just bring them both in. Yeah. Thank you. The left? Left, yep. Thank you. There's no left and right. There's not? No. Come south. Here, I want you to be bringing it this way so you're not hurting the skin, okay? Yeah. X-ray there. Good. Keep going. Keep going. Stop for a second. X-ray. Come up proximal. X-ray there. All right, so let's take that out. And we're gonna have to use the flexible reamers. Don't lose your wire.
We'll have an eight, and then we only have to get to nine. What do you have for us? The smaller of the two. Seven. Seven. All right. That'll be a good start. So it's pretty rare, but sometimes your standard reamer is set to eight five is the end cutting, but every so often you've got a tight canal and you gotta start with one of the flexible reamers. Good. Good. Do we have an eight? I have an eight by 315 and a nine by 315. Let's do an eight. Yeah, we'll do an eight. So I thought you said a left. It doesn't matter. It doesn't matter? Oh, you were just kidding me? Yeah, I was just messing with you. Thanks. Sorry. I was wrong. I'm out there trying to find a right or a left. Yeah. Sorry. For what? Didn't mean to. Yeah, I mean, come on, man. X-ray. Eight by 315, right? Cold PBI. Super cold. Is that an eight? Good. X-ray there. What's the most distal you can fix with a tibial nail? There's like a measurement like 0.5, something like a scar, two. It depends a lot on the fracture and the bone quality. That was eight. You wanna go to nine? Yep. We gotta do eight five, and then nine. So here's your eight five. How much irrigation? A bazillion. Six liters. We have lost very little blood. I'd say it'd be like 200. Excellent orthopedists. Is she opening a nail or running away? Whoa, whoa, whoa, whoa. Come south. We gotta ream all the way down to the bottom now. Come south. X-ray there. Okay. Good. X-ray. Nice. Keep going. Push hard. Push hard. What's that? Push hard. Up. X-ray there. Good. Your wire's coming out, I think. X-ray. Yeah, your wire's coming out, yeah. Mallet. There you go. That's it. That's it. Okay. Yep, go ahead. Do you really got it? Yeah, I already got it. It's spinning. No, it's spinning. Can you get a mallet? I can feel it spinning. You just gotta tap it. Get that thing back down. Try backing up. X-ray there. So part of the problem is you gotta back this out first. Back up a little bit first, and then move back down there? Yep. Back it up a little bit first. Back it up, please. Stop there. Now tap it down. There you go. That's good. X-ray. There you go. Right behind you. Nine, please. Good. All right, we'll take the nail. I like it. Blue. Tap, tap, tap. Mm-hm. X-ray there. Good. Okay. X-ray there. Good. X-ray there. X-ray. Come up proximal just a tiny bit. X-ray there. Nice. All right, good. Let's come up to the knee. Good. Proximal a little bit. Actually, x-ray there. Then come proximal a little bit more. Raise your machine. X-ray there. X-ray there. Good, so you drove your nail down to a good depth. Come down to the ankle again. Let's just make sure we're happy with our depth there. X-ray there. X-ray. X-ray there. Okay. I think we're pretty good. Let's give it just a tiny bit more of a tap. That's good. X-ray there. That's nice. X-ray there. X-ray. X-ray. Can you hold the knee for me? It's kind of hard. X-ray. Yeah, pull it back. Pull it back? X-ray. There you go. X-ray. There, so that's reduced. So we gotta go a little bit further. Come up to the knee. Good. X-ray there. X-ray. X-ray. That's probably pretty good. X-ray. Yeah, I like that. We're good. Okay. Do you have a blue marker? Blue marker? No, we're gonna close it, but we're gonna put an incisional back there. Incision back. 15, please. If that's dull, let me know. All right. Rule guide. Mallet. And then tap, tap. Good. Good reflex you had there. 32. Okay, drill. Oops. Just keep that in there. Fill. 34. 34? Yeah. Maybe even 36 actually. Acorn. Acorn. So that, once you pull it out, actually reduces quite nicely there. Yeah. And it's kind of bone grafted itself there, so we're gonna keep that in there. That's the beautiful about open fractures, you can just see it. Yep, that is correct. It's like cheating. No, but I wasn't really providing any extra. Oof. Next time, you'd never know this, but I like the long one. Okay. No, I tried it. I got stuck in the... Oh. Does the long one work on that now? Yeah. Oh, I don't know, actually, for a small one. X-ray there. Save that. So we have the nail driven down now. You can see it's completely beneath the surface of the bone, which is what we're looking for. But not too far down that if she has an infection or some problem, we can get it out. Come distal. And then the reason why... X-ray there. Keep coming distal. Save that. Come a little bit more distal. X-ray there. X-ray there. X-ray there. X-ray there. Save that. So that's not bad. We're at a tiny bit of recurvatum, but really not bad at all. And then let's come up to an AP. X-ray there. So I like our reduction. All right, come back towards you a little bit. X-ray. So the question now is just a matter of rotation. So our alignment is really nice in that plane. Yeah. X-ray there. That looks really good. This is just a matter of getting the reduction perfect. Do you have one more of these? Can you back out for a second? No, no, I need the... Do you have a Weity? Come on in there. So one of the challenging things here is to get rotation right. Sometimes you can use some of the fragments you had even though it's not perfect reduction. To get close. X-ray there. Back out for a second. So, we're short. Yep, there we go. Now come back in. X-ray there. That's pretty close. Back out again. Do you have a knife? Suck in here. Clinically, I agree with a little bit extra. Turn the foot in for me? Yep, there you go. No more, no more. Less, less. Just real subtle. Sorry. Now I lost it. Just real subtle. Okay. Suck. Pull hard. Okay. Come on in. Regardless, just see how that looks, clinically. So clinically, looks pretty good. We need our kneecap straight up. Looks pretty symmetric. Yeah. Good. X-ray there. Lets get rid of our clamp, yep. X-ray. X-ray. X-ray. Alright let's get a - give me a frog, halfway towards you. Good. X-ray there. Good. Now go lateral. X-ray. Pretty good. I think we have length there. X-ray there. X-ray there. That looks pretty good. Save that. All right. So I like that rotation. Clinically, it looks good. Just direct inspection, it's hard to cobble everything together perfectly. But everything seems to key together pretty nicely there. Once we have pointer reduction clamps, and try to get it slightly better. And you'll take it. Is there any special technique you would do if it's closed? If it's closed. Well, that's the advantage of having the other side in the field, is you get a cheat. You can get x-rays of the other side, AP and lateral of the knee. But it's very, very, hard. Really, the kind of trick that I use the most is getting multiple planes. You know, the cortices should all line up on all your x-rays. X-ray there. X-ray. All right. Let's come up to an AP. You know, it's not reasonable to expect that these are gonna anatomically reduce, because they weren't anatomically reduced when we reamed. Even if they were, the reamer would've pushed them away. And so, the tibia's just, you know, it's real tight, so it's just not gonna fit there. All right, good. So in a situation like this, we need lots of distal locking screws. X-ray there. Come distal, please. X-ray there. Do you have another couple towels? X-ray there. Can you arc over the top a tiny bit? X-ray there. X-ray there. That's good. Knife, please. 15. 15, please. All the AP and the lateral have always looked good, so I'm not too worried about it. X-ray. X-ray. X-ray. No. X-ray. My eyes aren't that good to see it with mag. Uh, no. Close, though. Close. We've got kind of a large wound. We got a large wound. X-ray. X-ray. X-ray there. Depth gauge. X-ray. It's not a regular one. There isn't a small exit though. X-ray. I'm pretty sure I drilled through that, but... Yep, there it is. 44. X-ray. Yep. X-ray. Miss. Yeah, you're not gonna save that one. X-ray there. X-ray. X-ray. X-ray. X-ray. X-ray. May be in it now. I think you were in. No, I don't think so. I think I missed it. I think I got it now though. X-ray. X-ray. X-ray. So that's in there. Yeah. The ankle feels fine. Okay. Yeah. I agreee. All right. Irrigate. Or, x-ray? Do you have a basin for me? Knee in. X-ray there. X-ray there. X-ray there. Screwdriver. We've got two more screws to put in, right? Yeah. X-ray there. Probably could be longer. That's okay. All right. 15 blade, please. Come up, so internally rotate. Yep, actually, come off lateral. That'll help too. Actually, you can relax a little bit. We're just, yeah, there you go. X-ray there. Can you lag south? No go north. Now pull back towards you. Good. Now go north. Now go up. It's too far. Subtle moves here, please. Now go up. Up. Good. X-ray there. Good. You're off mag. X-ray there. Come off lateral, please. There you go. X-ray. There you go. Tiny bit. X-ray there. There it is. Raise your machine a tiny bit. Good. X-ray there. And then, x-ray there. X-ray there. Can you come south just a tiny bit? Yep. X-ray there. X-ray. Lagging. X-ray there. X-ray there. X-ray. X-ray. X-ray. Bullseye. Of all the places in the known universe for your hand to be, that's the worst one. No, it's just you don't wanna be on the far side of the drill. Like that? Yeah, no, I know. But she has Hep C, you know what I mean. You don't wanna be anywhere near it. 36 shot. What was this one we put in the front, the top? 30. The first one? No, this last one we put in. 34. Are you sure? I thought was like 40 something. No, it was 34. Really? Yep. Pretty sure. Well, it needs to be longer than that. That's gonna be a 38. No wonder it's so short. All right. X-ray. I like to take a picture before I drive it home, so I still have access to the screw head to confirm that I'm right on target. That's a nice bite there. Good. Good thing. When they have these sure shot things and all that. X-ray. No. X-ray. Once you get pretty facile with perfect circles. X-ray there. Nope. You gotta internally rotate. X-ray. X-ray there. X-ray there. Just a tiny bit more proximal. X-ray there. It doesn't really give you that much, I don't think. 40. 40? Yep. Yeah, that maybe took a minute. X-ray. But I think if you're a low frequent surgeon, I think maybe some utility to it. But if you're doing a lot of these, it doesn't really. You get pretty used to it quickly. I think it's designed for people in the community. Do I change out that other screw? Yeah. Do we have this smaller? No, maybe she is dislocated. Or she just has a really funny ankle. It's that. Oh, yeah. Come south for me. Yeah, you're right. Right there. X-ray there. Yeah. Internally rotate a little bit. X-ray there. That looks... That looks okay. X-ray there. Let's get an oblique of the foot to be sure, but I think it's okay. Yeah, it's the same. That's just her - she's just flexible. Do you have a Freer? There's that anterior median bordering the tibia, you know that's a nice flat surface of bone. And there's that, you know, that's pretty similar. You know, it doesn't seem like we're turned in or out. There's the crest right there, there's a crest right there. They're lined up pretty well. I think we're pretty good, I think within five or 10 degrees, which is good. So, you don't always perseverate on it. And especially with an accommodated one, it's easy to mess it up. All right, why don't we... That's pretty good. Let's get our final x-rays, and then what I wanna do is get an AP of the knees, make APs of the knees. Oh, yeah. Screwdriver? We actually probably will not end up doing the traction. We'll see in a minute. We're gonna see. Can you measure this and give me a six longer? That kinda doesn't matter anymore. No. Yeah, I hear ya, man. X-ray. X-ray there. X-ray. Can you come to an AP? Yep. X-ray. X-ray. Screwdriver. X-ray.
CHAPTER 2
X-ray there. X-ray there. Will you come up to the knees, please? You know, radiographically, a little concerned about it. It's okay, but not perfect. Above the ankle or above the knee? The rotation, yeah. X-ray there. Could you swap that for me? Can you come back towards you? X-ray there. X-ray there. X-ray there. X-ray there. That's actually pretty similar. You know, there may be a few degrees out, but definitely not far. Not terribly. X-ray there. X-ray there. X-ray there. X-ray there. X-ray there. There. There. No, I mean, you gotta get the rotation right. Yeah, yeah. I think that's pretty good. I think I'm happy there. Okay. Raise the table for us, please. Yep. Coming up. Raise it up higher? That's good. Show me the knee, please. Push in, please. Push in, please. There you go. X-ray. X-ray there. Could you just make that straight up and down for me? Just one click over. The other way. One more click. Good. Save that. Come south. Keep coming south. Good. X-ray there. X-ray there. Pull back towards you a little bit. Yep. X-ray there. Come south. So those screws are long, but I think they're gonna be okay. Yep. X-ray there. No, that one's too long. What a hassle. All right, screwdriver. Go north. Take off four, I guess. The distal one's okay. Here you go. Yep. She's moving around a lot today. All right, come on south again. Show me the fracture. Yep. Come up proximal a little bit. X-ray there. X-ray there. X-ray there. X-ray there. Could you straighten that up for us? Just rotate it around one click or two. The other way. One more. Nope, back a bit. Back one. Back one click. There you go. X-ray. X-ray. X-ray. Save that. X-ray. X-ray. Save that. Come to a lateral, please. x-ray there. Could you drop the table for us, please? Good. X-ray there. X-ray there. X-ray. Save that. Come up proximal a little bit. X-ray. X-ray. Drop that. X-ray. Save that. Come up towards the knee, please. X-ray there. X-ray. Save that. All right. One last thing. X-ray there. Come south even further. X-ray there. X-ray there. All right. So to get a lateral of that, I gotta really twist it in. So that just makes sense. Come up to the knee. X-ray there. X-ray there. Yeah. X-ray there. So it's the same. X-ray there. She's like me, she's got a lot of external tibial torsion. Okay. Good. All right. Thank you. Come on out. We are done with x-ray. Irrigation, please. We got that three liters up, right? Yeah. Nothing more. No traction pin. Well, actually, show me the - I don't think so, show me the hip again. X-ray there. X-ray. X-ray. Come south. Back towards you. There you go. X-ray there. X-ray. X-ray. X-ray. X-ray. We just hold it reduced like that, huh? X-ray. X-ray. Yeah, we can put her in 15 pounds of traction. Won't hurt anything. Just make sure you're down here. I think it's fine. Whoever called us about the traction bow, can you say, "Yes, we need it." All right. Basin. All right, so why don't you get to sewing up there. Get that up. So to do a perfect tibial traction can you go from the fibula have to go basically, can you go from the tibia... So it can go Gerty's tubercle to tibial tubercle and you go like this, and that creates a safe arc. Uh-huh. So it creates an arc. Yeah, like this. So the ideal pin would be right there. Just a little distal. Yeah, just a little distal. You could probably be maybe a little bit, yeah, right about in there. Do we have some local? All right, I will take the nylon or the Vicryl. You want 2-0 or? 2-0, yeah. Adson. I'm cleaning that right now. Can I have a knife, please? Thank you. Half percent with epi, do you care? What's up? For local. Half percent with epi. Sure. Schnidt, please. Knife back. With epi? Yep, that'd be great. Do we have the correct open? There's some scissors out.
Scissors? I need some too. Just don't get it in the fibula. I won't do that. It's been done. Can you get me, do we have a bolt cutter? No. I want that extra pin that's in there. Yep. That's mine. I want you to take a bolt cutter, we're gonna need a bolt cutter, and cut off the tip, and I want this. Okay. And where do you usually like to aim at? Parallel. There you go. Back, please. Yep. Knife back. So Dr. Weaver, post-op pain for her, I'll have them leave the traction on. Non-weight bearing on the right side, weight bearing on the left. Weight bear less now. Not gonna weight bear at all? Transfer only. For a while? All right. Nada. When do you want me to have them make room for you somewhere back here? Monday. So do you need... Plan for Monday? No, it's okay. It's okay. We didn't need that. Had her on for planning of the proximal femur as well as... Yeah. The anti-coag will probably be per nurse. They're coming in pretty well. Yep. We should recommend a filter. Hey, Mark, thank you. That was good. That was good. Thank you. Can I see the bow? Bow coming in with x-ray? We'll do the x-ray real quick. All right, final picture time. Oh, okay. Washi, push in the C-arm, bro. Washi, come here. You're the C-arm man. Washi, push it. I need another 2-0, please. So next time. Come out here. Yeah. Should I do it again? No. It's a little closer. As long as it's enough on bone and bicortical. I'd like another 2-0, please. You wanna go to lateral and finish up right here? Save that. Get a lateral, yeah. X-ray. Save that. Nice shot, man. Looks good. I actually like it. I think it's perfect. I thought maybe you were a little posterior, but I think you're absolutely perfect. It looked, it just looked a little posterior.