Most of the times, large cortical fragments are present, proximally and distally, which allow restoration of adequate alignment between the main components of the fracture ( Figure 3). ĭirect reduction with small plates: a limited direct approach of the fracture site is performed, and one or two orthogonal 3.5 mm third-tubular plates are inserted to maintain proper fracture reduction and counteracting deforming forces. As cited before, special instrumentation is required, and careful selection of the entry point and initial trajectory of the guide must be verified. It also results very useful for expeditious reduction and nailing of distal fractures and facilitates intraoperative fluoroscopy ( Figure 2). The semi-extended position allows easy alignment of the proximal fragment with the diaphysis by neutralizing patellar tendon pull. A radiolucent pad or roller is held under the knee of the affected extremity with 10 or 20° of knee flexion, which is maintained during the procedure. Suprapatellar approach and semi-extended positioning: for this, a regular radiolucent table suffices. In conjunction with careful selection of a correct starting point, we utilize three methods to aid in proper reduction and counteract deformity forces: a suprapatellar approach with the leg in a semi-extended position, limited open reduction and provisional fixation with one or two one-third 3.5 mm plates, and the use of blocking (poller) screws to direct the path of the nail and facilitate proper reduction. If this angle is at the level or distal to the fracture, it tends to displace posteriorly the distal fragment.įor most surgeons, the optimal starting point is proximal to the anterior edge of the articular margin and slightly medial to the lateral tibial spine. Third, the nail design, in particular, is the so-called Herzog angle. The anatomy of the triangular-shaped proximal tibia and diaphysis causes the medullary canal to be aligned in correspondence to a point slightly lateral to the midline of the epiphysis. Second, valgus deformity also may occur, usually due to a combination of soft-tissue pull and misplacement of the starting point for nail insertion. Three factors should be taken into account to prevent malalignment: first, there is a natural tendency for the proximal fragment to hyperextend as the knee flexes, due to the pull of the patellar tendon. Roughly, even with modern methods for improving intraoperative reduction, malalignment remains up to 10% of the cases. Planning should consider the energy involved and “personality” of the fracture (open or closed fractures, concomitant injuries, damage to soft tissues, displacement of bone fragments, articular involvement, and quality of bone stock in the proximal fragment). Very proximal tibial fractures, which may include a simple articular split or depression fracture of one or both plateaus, are suitable for intramedullary fixation. Intramedullary nailing of far-proximal tibial fractures The authors present some strategies, technical considerations, and methods that have been useful for the achievement of these goals.ģ. Careful planning and surgical technique are essential for good reduction and stable fixation. Intramedullary nailing (extreme nailing) is a competent method for the management of these difficult injuries. These methods have shown good results in terms of quality of reduction and functional outcomes. Common surgical techniques include plates (either locking or nonlocking), locked intramedullary nails, and external fixators. The evaluation of the quality of soft tissues is key when selecting any method for surgical treatment. Aside from this, the soft tissue envelope is tenuous – especially at the distal tibia – and may result in damage due to trauma. A very proximal or distal fracture fragment, which may include intraarticular involvement, is difficult for proper reduction and alignment with the diaphysis, and at times, there is little bone stock available for solid fixation, either with plates or with nails. Tibial fractures located in the proximal and distal meta-epiphyseal areas pose a technical challenge for surgical management.
0 kommentar(er)
