Technical TrickAvoiding Neurovascular Risk During Percutaneous Clamp Reduction of Spiral Tibial Shaft Fractures: An Anatomic Correlation With Computed TomographyHorrigan, Patrick B. MD*; Coughlan, Monica J. MD†; DeBaun, Malcolm R. MD‡; Schultz, Blake MD‡; Bishop, Julius A. MD§; Gardner, Michael J. MD§Author Information *Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN; †Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, CA; ‡Department of Orthopaedic Surgery, Stanford University, Stanford, CA; and §Department of Orthopaedic Surgery, Stanford University Medical Center, Stanford, CA. Reprints: Patrick B. Horrigan, MD, Department of Orthopaedic Surgery, Regions Hospital, 640 Jackson St, Mail Stop 11503L, St Paul, MN 55101 (e-mail: [email protected]). J. A. Bishop is a paid consultant to Globus Medical and has received royalties from Innomed, research support from Zimmer, and other financial or material support from Synthes. M. J. Gardner is a paid consultant to Biocomposites, BoneSupport AB, Conventus, KCI, and Pacira Pharmaceuticals; is a board or committee member of the American Orthopaedic Association, Current Opinion in Orthopaedics, the Journal of Orthopaedic Trauma, the Orthopaedic Research Society, and the Orthopaedic Trauma Association; receives research support from SMV Medical and Synthes; has stock or stock options held in Conventus and Imagen Technologies; receives publishing royalties from the Journal of Bone and Joint Surgery and Wolters Kluwer Health–Lippincott Williams & Wilkins; and is a paid presenter or speaker for Miami Medical. The remaining authors report no conflict of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jorthotrauma.com). Journal of Orthopaedic Trauma: September 2018 - Volume 32 - Issue 9 - p e376-e380 doi: 10.1097/BOT.0000000000001239 Buy SDC Metrics Abstract Summary: The use of percutaneous clamps is often a helpful tool to aid reduction and intramedullary nailing of distal tibial spiral diaphyseal fractures. However, the anterior and posterior neurovascular bundles are at risk without careful clamp placement. We describe our preferred technique of percutaneous clamp reduction for distal spiral tibial fractures with a distal posterolateral fracture spike, with care to protect the adjacent neurovascular structures. We also investigated the relationship between these neurovascular structures and the site of common percutaneous clamp placement. Preoperative computed tomography images of surgically managed patients who sustained this specific common fracture pattern (distal third spiral diaphyseal tibia fracture with a posterolateral fragment) were retrospectively reviewed. On computed tomography, we extrapolated the ideal virtual clamp site on the posterolateral fracture fragment to facilitate reduction. The average distance of this clamp position from the anterior neurovascular bundle was 14 mm (SD = 7.6), with a range of 6–32 mm. The average distance of the clamp site from the posterior neurovascular bundle was 19 mm (SD = 6.1), with a range of 11–30 mm. In 31% of patients, the distal fragment's apex extended anterior to the interosseous membrane, and in 69% of patients, the apex was posterior to the interosseous membrane. We also describe our preferred surgical technique with percutaneous clamping and tibial nailing, which involves sliding the posterolateral tine of the percutaneous clamp along the lateral tibial cortex to prevent neurovascular bundle injury. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.