INTERLOCKING TIBIA NAIL IN SHAFT TIBIA FRACTURE PPT BY DR PRATIK

COMPLETE OPERATIVE STEPS OF INTERLOCKING TIBIA NAIL IN TIBIA SHAFT FRACTURE

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- LENGTH OF NAIL TO BE USED DIAMETER OF MEDULLARY CANAL TIBIAL TORSION

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

6. APPROACHES- C . SUPRAPATELLAR PATELLAR TENDON SPLIT 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 PREVENT GUIDEWIRE FROM BEING PARTIALLY WITHDRAWN PREVENT IATROGENIC COMMINUTION ADVISED REAMING WITH TOURNIQUET DEFLATED.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 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.

19. THANK YOU