This document summarizes the process of intramedullary nailing for tibial shaft fractures. It describes the components of the tibia nail, including its proximal and distal parts. It outlines the pre-operative measurements and patient positioning needed, as well as the surgical approaches, incision, entry point, reaming, and insertion of the nail. The positioning of the fully inserted nail is described. Both proximal and distal interlocking screws are then placed to provide stable fixation of the fracture, followed by suturing and post-operative care.

1. INTRAMEDULLARY
NAILING OF TIBIAL
SHAFT FRACTURES
DR PRATIK AGARWAL
DR SHANTANU DESHPANDE

2. IMPLANTS-

3. TIBIA NAIL-
• PROXIMAL PART WIDER WITH 2
HOLES
 PROXIMAL OVAL HOLE FOR
DYNAMIC FIXATION
 DISTAL ROUND HOLE FOR
STATIC FIXATION
• HERZOG BEND- 110* BENT
POSTERIORLY TO CORRESPOND
TO PROXIMAL TIBIA.
• DISTAL END IS NARROWED
WITH 3 HOLES
HERZOG BEND
PROXIMAL HOLE FOR
DYNAMIC FIXATION
DISTAL HOLE FOR STATIC
FIXATION

4. PRE OPERATIVE MESUREMENTS-
A. LENGTH OF NAIL TO BE USED
B. DIAMETER OF MEDULLARY CANAL
C. TIBIAL TORSION

5. POSITION OF THE PATIENT-
A. FRACTURE TABLE WITH CALCANEUM TRACTION
PIN
B. STANDARD TABLE USING ANGLE FRAME
C. STANDARD TABLE WITH 2 EXTERNAL FIXATOR
TRACTION

6. APPROACHES-
C. SUPRAPATELLAR
A. PATELLAR TENDON SPLIT
B. PARAPATELLAR-
• MEDIAL (COMMON)
• LATERAL

7. INCISION-
• MIDLINE INCISION FROM INFERIOR
POLE OF PATELLA TO TIBIAL
TUBERCLE.
• INCISION IS MADE ALONG MEDIAL
BORDER OF PATELLAR TENDON
AND TENDON IS RETRACTED
LATERALLY.

8. ENTRY POINT-
MEDIAL SLOPE OF LATERAL TIBIAL SPINE ON AP RADIOGRAPH.
JUST ANTERIOR TO ARTICULAR SURFACE ON LATERAL RADIOGRAPH.

9. ENTRY OF GUIDE WIRE-

10. REAMING-
• START WITH SMALLEST DIAMETER UPTO
MAX DIAMETER.
• INCREAMENT BY 0.5 MM.
• PRECAUTION-
 AVOID EXCESS REAMING OF ANTERIOR
CORTEX.
 PREVENT GUIDEWIRE FROM BEING
PARTIALLY WITHDRAWN
 PREVENT IATROGENIC COMMINUTION
 ADVISED REAMING WITH TOURNIQUET
DEFLATED.
 REAM THE ENTRY SITE LARGE ENOUGH
TO ACCEPT THE PROXIMAL DIAMETER
OF NAIL.

11. EXCHANGE TUBE-
BEADED GUIDE WIRE TO BE EXCHANGED BY
UNBEADED GUIDE WIRE USING EXCHANGE
TUBE

12. MEASUREMENT OF NAIL TO BE USED-
• DIAMETER- 1 MM OR 1.5 MM SMALLER THEN LAST REAMER USED.
• LENGTH-
 PREOPERATIVELY FROM TIBIAL TUBEROSITY TO MEDIAL MALLEOLUS.
 SYSTEMIC SPECIFIC DEPTH GAUZE.
 BY USING 2 GUIDE WIRE OF SAME LENGTH.

13. ATTACHMENT OF INSERTION DEVICE-
• PROXIMAL BEND POSTERIORLY
• INSERTION DEVICE MEDIALLY

14. INSERTION OF NAIL-
• INSERTION OF NAIL WITH KNEE
FLEXED TO AVOIND IMPINGEMENT OF
PATELLA.
• EVALUATE ROTAIONAL ALINGEMENT.
• MODERATE MANUAL PRESSURE WITH
GENTLE BACK AND FORTH TWISTING
MOTION.
• GUIDE WIRE REMOVED.

15. POSITION OF FULLY INSERTED NAIL-
• PROXIMAL END SHOULD LIE 0.5 CM TO 1 CM
BELOW THE CORTICAL OPENING.
• DISTAL END SHOULD LIE 0.5 CM TO 2 CM
FROM SUBCHONDRAL BONE OF ANKLE JOINT.

16. PROXIMAL
INTERLOCKING
SCREW
SCREW PLACED AND CONFIRMED THE
POSITION
MEASURE THE SIZE OF SCREW USING
DEPTH GAUZE
DRILL BOTH CORTEX USING DRILL
BITT
INCISION
• BOLT OF SIZE 4.9 MM IS USED.
• DIRECTION FROM MEDIAL TO LATERAL.
• KNEE SHOULD BE FLEXED.
• SCREW SHOULD BE PLACED WITH THE HELP OF
INSERTION DEVICE.
• MINIMALLY COMMINUTED TRANSVERSE
DIAPHYSEAL FRACTURE CAN BE DYNAMICALLY
LOCKED.
• COMMINUTED OR METAPHYSEAL FRACTURE CAN
BE STATICALLY LOCKED.
• PROXIMAL INTERLOCKING SCREW CAN BE
PLACED WITH KNEE EXTENDED AFTER REMOVING
THE INSERTION DEVICE TO PREVENT ANTERIOR
ANGULATION.

17. DISTAL
INTERLOCKING
SCREW-
• FREE HAND TECHNIQUE
• PERFECT CIRCLE SHOULD BE SEEN UNDER C-
ARM TO KNOW THE DIRECTION.
• PLACE DRILL BITT DIRECTLY OVER CIRCLE.
• 2 DISTAL SCREW SHOULD BE PLACED
• BOLT OF SIZE 4.9 MM IS USED IF NAIL OF SIZE
MORE THEN 8 MM IS TAKEN.
• BOLT OF SIZE 3.9 MM IS USED IF NAIL OF SIZE 8
MM IS TAKEN.
• IF FRACTURE SITE IS DISTRACTED THEN WE
SHOULD PLACE DISTAL SCREW 1ST

18. SUTURING AND DRESSING-
• PATELLAR TENDON MUST BE SUTURED BEFORE CLOSURE.
• ASEPTIC DRESSING WITH COMPRESSION BANDAGE SHOULD BE DONE.
POST OP CARE-
• EARLY RANGE OF MOVEMENT WITH NON WEIGHT BEARING WALKING WITH WALKER SHOULD BE
STARTED.
• WEIGHT BEARING SHOULD BE ALLOWED ONLY AFTER CALLUS FORMATION SEEN RADIOLOGICALLY
(4- 6 WKS POST OP).
• IN TRANSVERSE DIAPHYSEAL FRACTURE WHERE AXIAL STABILITY IS PRESENT, EARLY WEIGHT
BEARING WALKING CAN BE STARTED.

20. THANK YOU