Now that the fracture is reduced, definitive fixation must be applied and maintained throughout the patient's time to osseous union. Techniques to improve the definitive intramedullary fixation are as follows:
Up to a third of distal third tibial fractures have an associated intraarticular component, either as an extension of the primary fracture line or as a distinct plafond segment.25–27 Distal third tibial shaft fracture location, spiral type fracture pattern, or an associated spiral fibula fracture is predictive of an intraarticular component.28 Because of this, we recommend a CT through the ankle joint in addition to careful oblique imaging with intraoperative fluoroscopy. If such an injury is found, we recommend independent management of the intraarticular segment before nailing of the shaft component.29,30
Treatment of distal tibia fractures with an intramedullary implant can be complex and challenging, but it does not have to be stressful or difficult. Careful preoperative evaluation and meticulous tactical planning will allow the surgeon to enter the operating room ready to execute the plan. Simplify the case by having the knee in a semi-extended position for easier imaging and access, through use of existing external fixators or universal distractors, and by being able to deftly select from a variety of reduction methods including the utilization of blocking screws and unicortical plate fixation. Lastly, it is important to fully use the selected intramedullary nail and available distal bone to obtain multiple points of fixation.
The authors acknowledge Samir Mehta, MD, Department of Orthopaedic Surgery, University of Pennsylvania for providing clinical radiograph for figures.
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