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Peggers’ Super Summary Tibial Shaft Fractures Indications: NAILING Tibial Diaphyseal Fractures PLATING Tibial Diaphyseal Fractures Non-unions and mal-unions Comminuted fractures Operative Room Planning INTRODUCTION Confirm Consent / Mark / WHO form / Abx at induction POSITION SUPINE Bolsters to position knee at 90 0 DRAPING Antiseptic solution from midthigh to include whole of foot Perforate drape around midthigh Anatomy: The entry point can damage the proximal tibia, menisci, intermeniscal ligament and articular cartilage Geniculate nerves Associated injuries Detailed neurological nad vascular assessment included ABPI Compartment syndrome Intra-articular extension especially with spiral fracture patterns – CT if there is any concern Tibial compartments o Anterior – Tibialis anterior, EHL, EDL, peroneus tertius Deep peroneal and anterior tibial artery o Lateral – Peroneals and superficial peroneal nerve o Posterior – Gastrocnemius, soleus, Plantaris, sural cutaneous nerve o Deep Posterior – (TDH) Tib post, Flexor digitorum, FHL, tibial nerve and posterior tibial nerve Preoperative Planning: Often flexed and in varus Review imaging to see fracture extension o Extension or second fracture of the femoral neck Femoral properties o Femoral length o Canal diameter o Neck shaft diameter Equipment Prosthesis o Intramedullay Tibial nail o Extramedullary Plate (LCDCP or MIPPO) radiolucent table Bolsters to position knee straight and at 900 II Reduction tool such as Haygroves, Schanz, femoral distracter Surgical Approach NAILING Longitudinal approach o Vertical incision from tibial tuberosity to patella o Poorer healing from crossing Langer’s line o Risk of damage to lateral geniculate nerve o Easier exposure Transverse approach o 6-8 cm incision horizontal midway between knee joint and tibial tuberosity o Uses Langer’s lines and no nerve damage Subcutaneous dissection via medial or lateral parapatella approach Place the bone awl on the anterior ridge of the tibia 1cm below joint line in line with the canal. Push the awl through the cortex making sure the awl is parallel with the tibia (to avoid damaging the posterior cortex) Use a hand reamer in the proximal canal Pass a tipped wire into the canal and guide it past the fracture site Failure of closed reduction consider opening; o Provisional plating o Reduction tools o Schanz pins to joystick the fragments together o Femoral distractor o Poller screws placed across the canal to direct the guide wire or reamer Distally the guide wire should be central on AP / Lat II REAMING Use a tissue protector when reaming Ream sequentially until chatter at the isthmus Careful not to blow the fracture apart Reaming slowly and with sharp reamers to avoid thermal necrosis Page 1 of 2 Peggers’ Super Summary Tibial Shaft Fractures NAILING Measure the nail length Check that the fracture is reduced before the nail is passed Introduce the nail and careful not to rotate the nail Check distal and proximal positions on II and as the nail passes the fracture site Bury the proximal nail but not too much in case it needs removing Check rotation before inserting screws DISTAL SCREW INSERTION Align C arm 900 to the leg Adjust the leg or c arm so that the screw holes are ‘perfectly round’ Make a 1cm skin incision over the hole Use a drill piece and align with the hole During drilling if in doubt remove drill but leave drill piece in situ to check positioning Drill through both cortex’s and measure before inserting correct PLATING Use a tourniquet Spiral fracture need lag screws and neutralisation plates. Whilst comminuted fractures need plates in bridging mode Low compression dynamic compression plate (LCDCP) or (Minimally Invasive Percutaneous Plate Osteosynthesis) MIPPO technique to minimally disturb periosteal tissues and blood supply Cortical screws 4.5, cancellous screws 6.5mm Compression side of plate with open tension side of bone, can be overcome with bending at the fracture site Approach is via a 1-2cm lateral incision to the crest of the tibia Incise deep fascia Plate can be placed on the medial or lateral tibia, if medially use sharp dissection to raise flat extraperiosteally. Lateral place placement is preferable as there is less skin irritation Plates are placed extraperiosteally Closure Irrigate ++ Haemostasis Fascia not closed 2/0 vicryl for fat and subcutaneous 3/0 caprosyn for subcuticular 3/0 nylon or vicryl rapide for the skin Dressings Evidence: >50 angulation in any plan has a 25% risk of loss of fixation. Lang GJ et al. Clin Orthop Related Research 1995. Trans patella approach no different in pain or movement than para-patella. Vaisto O et al. J Trauma 2008. Complications: Early Infection Periprosthetic fracture Knee pain Late Knee pain – only eason to remove nail Non or Malunion Nail breakage Finishing off: Check alignment o Rotation and < 50 acceptable Check knee ligaments Page 2 of 2