1) Proximal tibia fractures make up 58% of tibia fractures and are prone to deformity in the coronal and sagittal planes without proper treatment. 2) A poller screw is a blocking or supporting screw that can be used to guide an intramedullary nail and prevent deformity in proximal tibia fractures. 3) By providing three-point fixation, a poller screw counters the deforming forces of muscles and ligaments to stabilize the fracture and ensure proper alignment during healing.

1. Poller Screw in Proximal Tibia
Fracture
Suresh Pandey
Professor and Head, Dept. of Orthopedics
College of Medical Sciences, Bharatpur
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2. Background
• Proximal tibia fracture 11%
• Deformity in coronal and sagittal
plane
• Amenable for nailing if >6-7 cm
length
Traumacon 2022 Nepal Tibia Nailing

3. Prevalence
• 58% for proximal tibia fractures
• 14% for distal tibia
Freedman E, Johnson EE. Radiographic analysis of tibial fracture malalignment following intramedullary nailing. Clin Orthop
Rel Res 1995;315:25–33
Traumacon 2022 Nepal Tibia Nailing

4. Why deformity?
• Displacing force
• Mismatch
medullary cavity
and nail
• Wrong nail entry
and trajectory
Tornetta P. Clin Orthop Relat Res 1996;328:185–9.
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5. Common deformity
• Apex anterior
• Valgus malalignment
• Anterior displacement of the proximal fragment
Traumacon 2022 Nepal Tibia Nailing

6. Sagittal plane Displacing forces
• Pull of the patellar tendon
• Pull of the anterior compartment muscles
• Lack of a posterior cortex
• Wedge effect of the bent nail in the distal fragment
• Medial starting point
• Low starting point
Herzog angle
Traumacon 2022 Nepal Tibia Nailing

7. Coronal plane Deforming forces
• Medial starting point
• Lateral direction of nail
Traumacon 2022 Nepal Tibia Nailing

8. Pathomachanics
• Wrong entry point
• Wrong trajectory
• Wide medullary cavity in
metaphysis
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9. • Mismatch cavity and nail size
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10. What Better could have been done?
• Proximal entry point
• Correct entry point and
trajectory
• Suprapatellar approach
• Semiextended position
• Prior reduction
• Unicortical plate/ext fix
• Poller screw
Traumacon 2022 Nepal Tibia Nailing

11. What is Poller screw
BOLLARD Krettek et al 1999
Blocking screw
Transmedullary
supporting screw
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12. How It works?
• Guides nail to centre and block in wide metaphysis
• Narrows wide metaphyseal medullary cavity
• Increases implant bone construct stability
Krettek C. J Orthop Trauma 1999;13:550–3.
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13. Principle…
• Poller screws act via a 3-point fixation principle to nullify the forces of
muscle and ligament pull and narrow the metaphysis play
TH E JOURNAL OF BONE & JOINT SURGERY · JBJS.ORG VOLUME 86-A ·
SUPPLEMENT 2 · 2004
Traumacon 2022 Nepal Tibia Nailing

14. Principle…
• Soft-tissue imbalance, which acts as a tension band, is counteracted
by three-point fixation.
Traumacon 2022 Nepal Tibia Nailing

15. Surgical Techniques: Concave side of
deformity, short fragment and close to CORA
Site
Number
Screw Type
Stedtfeld HW, Mittlmeier T, Landgraf P, Ewert A. The logic and
clinical applications of blocking screws. J Bone Joint Surg
Am2004;86(Suppl 2):17–25.
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16. Short and short rule
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17. Number of Screw?
• One: concave side, short fragment, close to Fracture
• Two: second opposite to 1st, far in the short fragment, convex side
• Three: 2 in wide metaphysis, 1 long segment
Traumacon 2022 Nepal Tibia Nailing

18. Which screw?
• 3.5 mm or 4.5 mm cortical screw
• Locking screw
• Steinman pin
K wire and Drill bit better avoided
Locking screw
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19. Timing
• Before reaming
• Before advancement of nail
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20. Case Illustration
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21. Distal 3rd tibia
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22. Take Home Message
• Understand the anatomy, fracture location and deforming forces
• Nail does not reduce fracture unlike in Isthmus area
• Blocking screw useful tool to avoid malalignment in proximal tibia #
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23. Thank You
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