6. APPROACH
Determination of the entry
point
In the frontal plane, the
entry point is located in line
with the medullary canal (3
mm medial of the tibial
crest). In the sagittal plane,
the entry point should be
located just distal to the
angle between tibial
plateau and anterior tibial
metaphysis.
7. To find the correct entry
point, identify the tibial
crest and place a guide
wire along it, extending
proximally over the
knee.
The correct insertion
point will be at the
intersection of the guide
wire with the tibial
plateau.
8. SKIN INCISION
Make a longitudinal skin
incision over the planned
entry point. Extend it 3-5
cm proximally from the
level of the tibial plateau.
9. TENDON INCISION
The incision may go either
through or around the patellar
tendon
For fractures of the midshaft or
below, the incision and starting
point is just medial to the
patellar tendon
In proximal third fractures, the
incision and starting point is just
lateral to the patellar tendon
10. CREATION OF THE NAIL
ENTRY SITE
Placement of the guide pin
Insert a finger through the
incision and palpate the
anterior edge of the tibial
plateau.
With the finger in place,
insert a guide wire just
distal to the finger,
essentially just beyond the
angle between plateau and
proximal metaphysis.
11. INSERTION OF THE GUIDE PIN
Frontal plane:
Insert the guide wire aiming down the tibial
crest, and thus the center of the medullary
canal.
Sagittal plane:
Press the guide pin into the bone so the tip
does not slip. While entering the bone,
correct the guide pin alignment by pushing
the proximal end of the pin posteriorly. This
brings the pin almost in line with the axis of
the tibia, as illustrated.
13. GUIDE WIRE INSERTION
Ball-tipped guide wire
Once the proximal metaphysis
is breached, pass a ball-tipped
guide wire down the
medullary canal into the distal
metaphysis
14. FRACTURE REDUCTION
Manual traction
Depending on the patient’s
positioning and type of OR
table, one or two people may
be required to perform
manual traction
It provides “countertraction”
when the fracture is
lengthened with distal
traction.
15. DETERMINATION OF NAIL LENGTH
Nail length is estimated
preoperatively, but
intraoperative measurement
is more precise
Use a radiographic ruler,
provided with the nail’s
instruments
With the fracture reduced,
measure the distance from
the planned nail entry site
to just above the ankle joint
16. REAMING
Apply the sleeve/reamer protector
to protect soft tissue
Insert the cannulated, flexible-shaft
reamer over the ball-tipped guide
wire
Begin with an end-cutting reamer
and proceed sequentially to larger
reamer diameters, usually in
increments of 0.5 mm
Do not force the reamer!
Off the tourniquet to avoid thermal
necrosis
17. DETERMINATION OF NAIL DIAMETER
A radiographic gauge,
as illustrated, helps
assess the medullary
canal diameter
Reaming should be to
0.5 to 1.5mm greater
than nail diameter
18. NAIL INSERTION
With adequate reduction and sufficient over-reaming, it should be possible to insert the cannulated nail over
the guide wire by hand, or with gentle hammering
Ensure that reduction is maintained
If insertion is difficult, correct the reduction and/or remove the nail and ream to a larger diameter
Make sure that the proximal end of the nail is below the surface of the bone at the entry site, to decrease the
risk of knee pain
19. LOCKING OF THE NAIL
Proximal locking
Use the jig and sleeve to guide
the insertion of proximal screw
Don’t ever loose the jig from the
nail untill proximal screw inserted
20. DISTAL LOCKING
Distal screw can inserted
with fluoroscopic
guidance in lateral
position
Using “ Full Moon”
technique
Screw length
and placement can be
confirm radiographically
21. NAIL CAPPING AND WOUND
CLOSURE
Remove the insertion handle and its connecting screw
Insert an end cap, if desired, to prevent ingrowth of bony
tissue, which will interfere with nail removal
Repair the patellar tendon and its paratenon with
interrupted sutures
Skin and subcutaneous tissue are closed with a few loose
sutures, which should be left in until the wound is securely
healed
