Tibial Intramedullary Nailing

Indication. A displaced or unstable diaphyseal (shaft) tibial fracture that cannot be held in an acceptable position in a cast — the great majority of closed shaft fractures and many open shaft fractures. Nailing is also indicated for segmental fractures (a single load-sharing device spans both levels), for polytrauma (to allow early mobilisation and reduce systemic complications), and for most open tibial shaft fractures after debridement and antibiotics. Harder cases (relative indications). Very proximal or very distal metaphyseal fractures give the nail little canal purchase and are technically demanding — plan for a suprapatellar entry, blocking screws, multiplanar locking and (distally) fibular fixation, and accept that plating is a reasonable alternative when nail control is inadequate. Fractures with an intra-articular extension need supplementary screw fixation of the joint surface first. Contraindications. Absolute: active sepsis at the entry site or within the canal, and skeletal immaturity with open physes (the entry point threatens the proximal tibial physis). Relative: gross contamination precluding internal fixation (use temporary external fixation, then convert), a pre-existing deformity or a very narrow or obliterated canal, and significant patellofemoral pathology if a suprapatellar approach is planned. The two decisions that matter. Whatever the fracture, the operation is the same locked nail — the real choices are the approach and whether to ream.

Consent specifically for anterior knee pain (common, especially after infrapatellar nailing), malalignment (particularly proximal and distal third), infection, nonunion or delayed union (higher in open and high-energy injuries), compartment syndrome, neurovascular injury (the superficial peroneal nerve at distal locking), and hardware or locking failure — including the possibility of later removal that may not relieve the knee pain. Setup. Supine on a radiolucent table with an image intensifier that can obtain true AP and lateral views of the knee, shaft and ankle. General or regional anaesthesia with prophylactic antibiotics; a tourniquet may be applied but should be deflated during reaming to reduce thermal necrosis. The detailed positioning for each approach is covered in Step 1 below.

The goal: establish a perfect start point through the chosen approach, reduce the fracture, ream (for a closed fracture) to accept a large stiff nail, pass the nail, lock it proximally and distally, and use blocking screws and fibular fixation to control the metaphyseal fragments — all while protecting the patellofemoral cartilage, the popliteal vessels posteriorly and the superficial peroneal nerve distally. The exposure is laid out in full as the first steps.

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Post-operative protocol | Phase | Timing | Weight-bearing & immobilisation | Therapy & monitoring | |-------|--------|----------------------------------|----------------------| | Early | Day 0 to 14 | Serial neurovascular and compartment checks; elevate the limb | Stable transverse or short-oblique patterns — weight-bearing as tolerated; comminuted, segmental or metaphyseal — protected partial weight-bearing. Multimodal analgesia (escalating need is a red flag for compartment syndrome); thromboprophylaxis | | Rehabilitation | 2 to 6 weeks | Advance weight-bearing as callus appears | Knee and ankle range of motion; serial AP and lateral radiographs to confirm union | | Return to function | 6 weeks to 6 months | Full weight-bearing once united | Strengthening and proprioception; light or desk work within a few weeks, manual work and sport typically once united (around 3 to 6 months) | | Hardware | Beyond union | Nail removal only if symptomatic, commonly beyond a year | Counsel that removal may not relieve anterior knee pain | Special situations - Open fractures. Give antibiotics early (ideally within an hour) and tetanus prophylaxis, and thoroughly debride devitalised tissue before definitive fixation. Nailing is acceptable for many open shafts after debridement — reamed and unreamed nailing show no significant difference in open fractures (SPRINT). Plan combined orthoplastic "fix-and-flap" cover for high-grade (IIIB) injuries, and use temporary damage-control external fixation first in the unstable polytrauma patient or a grossly contaminated wound, converting to a nail once the patient and soft tissues allow.

• Proximal third. Deforms into apex-anterior and valgus — use the semi-extended or suprapatellar approach, a correct anterior-enough start point, and blocking screws on the concave side; confirm alignment carefully on the lateral view, where procurvatum is easily missed.
• Distal third. Limited distal segment for fixation — use at least two, ideally multiplanar, distal interlocks, blocking screws, and consider fibular plating to restore length and resist valgus; plating is a reasonable alternative when nail control is inadequate. Complications

Epidemiology. The tibial shaft is the most frequently fractured long bone, classically in a bimodal distribution — high-energy fractures in young men (motor vehicle and sporting trauma) and low-energy fractures in older adults — with open fractures common because of the thin anteromedial soft-tissue envelope. The proximal third carries the highest risk of acute compartment syndrome. Surgical anatomy. The tibia is subcutaneous along its anteromedial border, which explains both the frequency of open fractures and the importance of careful soft-tissue handling. The proximal articular surface slopes posteriorly, so on the lateral image the anterior down-slope of the plateau marks the correct sagittal entry. The tibial tuberosity and patellar tendon are the infrapatellar landmarks; the quadriceps tendon and patella are the suprapatellar landmarks. Biomechanics of the intramedullary nail. An IM nail is a load-sharing device positioned along the mechanical axis — it shares load with the surrounding bone, unlike a plate which is largely load-bearing. Working length is the unsupported length of nail between the proximal and distal points of fixation across the fracture; a longer working length reduces bending and torsional stiffness, so minimising the comminution gap and using a well-fitting nail matter. A larger-diameter (reamed) nail has greater bending and torsional stiffness and allows larger interlocking screws, and the interlocking screws themselves control length and rotation, converting the nail into a stable construct in unstable patterns. Why proximal-third fractures deform. In the proximal third the wide metaphysis gives the nail little endosteal contact, so the fragment is controlled by soft tissues, not the implant. The classic deformity is apex-anterior (procurvatum) and valgus: the patellar tendon and extensor mechanism extend the proximal fragment (apex-anterior) when the knee is flexed for infrapatellar nailing, and the pes anserinus and medial structures contribute to valgus. The countermeasures are a sufficiently anterior start point, the semi-extended (suprapatellar) position, and blocking screws on the concave side. Neurovascular structures at risk. The superficial peroneal nerve is at risk with lateral-to-medial distal locking — use a careful open or free-hand perfect-circle technique and protect the soft tissues with a sleeve. The popliteal vessels lie posterior to the proximal tibia, so avoid over-penetration posteriorly with guide wires and reamers. The saphenous nerve and vein run along the medial leg and are at risk during medial approaches and distal medial locking. In the suprapatellar approach the patellofemoral cartilage is at risk, mitigated by a protective sleeve and case selection. The fibula in tibial fractures. In distal-third tibial fractures an associated fibular fracture allows the tibia to drift into valgus and shorten. Plating the fibula first restores length and resists valgus, improving the reduction before tibial nailing — particularly useful when distal nail control is limited. In mid-shaft fractures fibular fixation is usually unnecessary. Key evidence. The SPRINT trial (1319 patients across 29 centres) remains the landmark study: in closed tibial shaft fractures, reamed nailing reduced the rate of the primary composite outcome (reoperation events) compared with unreamed nailing, while in open fractures there was no significant difference between the two; it also advised not assessing reoperation events before six months. Katsoulis and colleagues established anterior knee pain as the leading long-term complaint after tibial nailing (commonly around 47% across pooled infrapatellar series), often only partially relieved by nail removal. Krettek and colleagues described the blocking (Poller) screw — placed on the concave side of the anticipated deformity to narrow the functional canal and steer the nail — for metaphyseal tibial fractures. Lack and colleagues showed that early antibiotic administration (within about an hour) reduces infection in open tibial fractures. The classic epidemiological description of tibial fracture patterns is Court-Brown and McBirnie, and the LEAP study informs limb salvage versus amputation decisions in severe open injuries.