Intramedullary Nail for Open Tibial Fracture
Table of Contents
The tibia is particularly susceptible to open fractures because of its subcutaneous location. The status of the overlying soft tissue is regarded as the key determinant of fracture management strategy. Intramedullary nailing is widely recognized by the orthopedic community as the treatment of choice for most displaced, open, tibia shaft fractures due to the extent of soft tissue damage and the risk of infection. Both open and closed fractures are amenable to nailing. Occasionally, plates and external fixators are required to manage certain tibial fractures.
This article describes the stabilization of an open tibia shaft fracture using an intramedullary nail. After copious irrigation and debridement of the fracture site, a transpatellar tendon split is used to expose the nail entry point. This is followed by fracture reduction, sequential reaming, and nail insertion and locking. Finally, the technique for proximal tibia traction pin insertion is demonstrated on the contralateral tibia.
Fractures of the tibial diaphysis can occur across the age spectrum and can present as the result of a variety of accidents. They range from high-energy, comminuted fractures often in younger patients to spiral fractures commonly seen in older patients from lower energy mechanisms. Tibia shaft fractures are commonly treated by both intramedullary (IM) nails as well as a screw and plate construct. Both methods have been shown to be effective and have a low risk of infection.1-4 Many times when the fracture is open, often in a younger patient from a high energy mechanism, an IM nail is preferred as it is less traumatic to the surrounding soft tissues.1 Here we describe the indications and methods for IM nail use in an open tibia shaft fracture.
These injuries are often the result of high-energy mechanisms, with motor vehicle collisions and sports accidents making up about 60% of cases and falls or assaults accounting for another 20% in one study.5 A full history should be obtained with details surrounding the event. Examples of relevant details could be if this patient was the driver or passenger, if restraints were worn, if airbags deployed, if there was a loss of consciousness, or if the patient had ever had any previous injuries or surgeries to the affected leg. All of these items can help guide the secondary exam and could have an effect on surgical planning. It is also important to evaluate the patient’s mental capacity and ensure injury or intoxication is not going to affect their ability to give informed consent.
It is important not to allow an open fracture to distract from a complete physical exam. Once the fracture site is evaluated, it should be cleaned of gross debris and contamination and washed with sterile saline. The attempted reduction should be done to try to keep the exposed bone covered with soft tissue and pressure of the skin in an effort to avoid skin necrosis. A neurovascular exam should be obtained, especially distal to the fracture site. If needed, a Doppler ultrasound can be used to determine if perfusion is intact distally. Any concern of disruption should prompt immediate vascular surgery consultation and a CT angiography to ensure vascular patency. It should be noted that on some occasions, reduction of a severely displaced fracture can allow for the return of perfusion in instances where there are no palpable pulses distally. Evaluation of sensation and motor functioning can help determine the extent of soft tissue damage prior to entering the operating room to help manage operative planning and postoperative expectations.
Because these are often a result of high-energy traumas, there are frequently concomitant injuries present in these patients. A thorough secondary exam is of vital importance to help prioritize care. In some instances, damage control orthopedic (DCO) care will need to be utilized. This might involve placing external fixation or skeletal traction temporarily while other injuries are addressed. It is also important to frequently check compartments on these patients as injuries of the tibia can result in compartment syndrome of the leg, even in open fractures.
Plain films are often used to characterize the location of the fracture and the fracture pattern. Images of the knee and the ankle should also be obtained in order to rule out any injury to the adjacent joints.
A fracture is described as “open” when there is a violation of the overlying skin. These injuries necessitate a trip to the operating room as there is a need for intraoperative irrigation and debridement, in which sterile saline is run into the wound to clean it out of any debris, and dead or devitalized tissue is removed. Using a construct from plate and screws is possible and favored by some, but IM nails are generally preferred in these instances as they allow for immediate weight-bearing and reduce soft tissue violation.1,2 It has been demonstrated, however, that there is a greater risk for malalignment with an infrapatellar nail than with a suprapatellar nail or a plate and screw construct.1
The goal of using an IM tibial nail is to achieve a reduction of the fracture site and provide a way to maintain that reduction postoperatively. IM nails also allow patients to immediately put weight on their extremities and allows for the earlier return of function, and decreased risk of complications, such as blood clots.6 Additionally, IM nails of the tibia have been found to have shorter operative times and are easier to remove.3 The disability score between nailing and plating at six months has been shown to be no different.7
As mentioned previously, in some instances of polytrauma, DCO is needed. This may alter the typical course of care that the patient would otherwise have received.
Once the patient is in the operating room, it is necessary to further open the wound and debride the fracture site and surrounding soft tissues. The incision should be big enough to expose the zone of injury. Once exposed, use a curette to debride necrotic tissue, and irrigate with 3-12 L of normal saline. After irrigation is complete, move on to obtaining the reduction of the fracture.
A triangle can be used to help position the leg in a manner most conducive to obtaining and maintaining reduction while still being able to use intraoperative fluoroscopy. The knee is kept in a flexed position in order to gain access to the proximal tibia where the nail will be inserted.
Mark out the opening incision with a marking pen. The incision for a transpatellar tendon approach is made using the anatomic landmarks of the inferior pole of the patella and the tibial tuberosity. The incision can be made in two passes, with a more superficial incision through the skin followed by a more aggressive deep incision to the level of the tibia. Care should be taken to only violate the tendon in the direction parallel with its fibers to facilitate closure and minimize tendon damage.
Following the opening incision, use a guidewire freehand to gain entry into the IM canal of the tibia. This should be started as far posterior as possible while still staying anterior to the articular portion of the plateau. It should be placed along the anatomic axis of the tibia and tapped into place using a mallet. In this approach, the desired starting point is just anterior to the articular surface of the tibial plateau and just medial to the lateral tibial spine. The position should be checked with fluoroscopy in order to verify starting point and trajectory before advancing the guidewire. Once it is verified in both anteroposterior and lateral views that the starting point and trajectory are acceptable, use a power wire driver to advance the wire. Once the wire is in the desired position within the canal, use the opening reamer to clear cortical bone from the path of the nail. Take care to fully seat the tissue protector against the cortical bone to spare iatrogenic damage to the articular cartilage and the surrounding soft tissues.
Next, remove the opening reamer, tissue protector, and wire and insert a ball-tipped guidewire to the level of the fracture. Use fluoroscopy to ensure the wire stays within the IM canal and does not exit through the fracture site. A small bend can be placed on the wire below the ball in order to help in directing the wire to the desired location. A T-handle chuck and mallet can be used to help drive in the wire if needed. The wire should be driven distally within the canal as centrally as possible to a point just proximal to the physeal scar above the plafond.
A ruler is then used over the wire in order to determine the length of the nail that is needed. The ruler should be seated all the way down on the cortical bone. Once the length of the nail is determined, reaming of the canal is needed. This allows for a better fit of the nail that fills the canal and provides better internal support. The smallest reamer should be placed over the guidewire and seated on the cortical bone before being attached to the power driver. A wire pusher should be used when backing the reamer out to maintain the wire’s position within the IM canal. Flexible reamers can be used if needed. When removing the reamer, it should be stopped within the canal proximally and removed by hand in order to protect the soft tissues. Reaming should be increased incrementally until chatter is observed at the diaphyseal isthmus.
Once the nail diameter is determined, it can be placed over the guidewire and into the IM canal. A strike pad attached to the nail can be used to allow for malleting the nail into place.
Once the nail is determined to be in the desired location using fluoroscopy, the targeting jig can be affixed, which will allow guidance in placing the interlock screws. A triple sleeve can be used in the jig to determine the entry point in the skin, and then an incision can be made with a skin knife. A Kelly clamp or hemostat can be used in the incision to clear away soft tissue from the screw path. Once done, the triple sleeve can be placed back in the jig and seated against the cortical bone. The middle piece of the triple sleeve is then removed and a drill is used to drill through both cortices. The depth can be measured off the drill depth guide or by hand, and the appropriate length screw should be introduced to lock the nail. This should be done for the available interlock screw positions. An acorn driver should then be used to remove the handle of the nail once the interlocks have been placed. The proximal interlocking screws can be used to fix the nail in the proximal bone, while the distal tibial fragment can be manipulated to obtain desired fracture reduction. Common tools to obtain reduction are the point of reduction clamps, axial traction, and rotation. Once this is done, the distal interlocking screws should be placed to maintain the reduction. The distal interlock screws are placed using the perfect circles technique. Once all interlocking screws are placed, leg lengths should be checked to ensure symmetry and rotation are appropriate. Final X-rays should be obtained to ensure reduction has held and all implants are in their desired locations.
Following confirmation that all implants are in place and reduction has been achieved, the wounds can be irrigated and closed. Deep closure can be done with Vicryl as demonstrated here. Care should be taken in closing the patellar tendon. Nylons or staples can be used to close the skin.
The patient is able to immediately bear weight following tibial IM nail placement. Nylons or staples should be removed two weeks postoperatively.
Tibial shaft fractures often occur in the setting of high-energy trauma and can have concomitant injuries, often requiring damage control orthopedics and staged procedures.8,9 Because of the scant amount of tissue covering the anterior tibia, these can often present as open fractures. Long bone fracture management is a crucial aspect to stabilizing a patient and internal stabilization using an IM nail within the tibia is an excellent option for definitive fixation following tibial shaft fracture as it allows for immediate weight-bearing as well as necessitates minimal soft tissue disruption.8
Each patient should be evaluated on a case-by-case basis to prioritize the order and manner in which the injuries should be addressed. Generally, the outcomes are favorable for these procedures.
The SPRINT trial investigated prognostic factors that can help stratify outcomes for patients preoperatively. These factors are high energy trauma, a fracture gap, full weight-bearing postoperatively, use of a stainless steel implant (as compared to titanium), and open fractures with the reamed insertion of an implant. However, reaming was found to be of benefit to closed fractures. Additionally, open fractures that were able to be closed and required no additional soft tissue procedures were not found to be statistically different for adverse outcomes.9 This procedure is common to orthopedic surgery as the tibia is the most frequently fractures long bone in the body and is generally well tolerated with good outcomes. This has been an overview of the indications, common presentations, and operative details for placement of a tibial IM nail using a trans-patellar tendon split approach in the setting of an open tibial shaft fracture.
- Ball-tipped guidewire
- Portable fluoroscopy system
- Flexible reamers
- Tibial nails
- Interlocking screws
Nothing to disclose.
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
The article is written by Dr. Caleb Gottlich and under review by Dr. Michael J. Weaver.
- Kwok, Chun Shing MBBS; Crossman, Paul T. FRCS (Tr and Orth); Loizou, Constantinos L. MRCS Plate Versus Nail for Distal Tibial Fractures: A Systematic Review and Meta-Analysis, Journal of Orthopaedic Trauma: September 2014 - Volume 28 - Issue 9 - p 542-548. https://doi.org/10.1097/BOT.0000000000000068
- Vallier, Heather A. MD Current Evidence: Plate Versus Intramedullary Nail for Fixation of Distal Tibia Fractures in 2016, Journal of Orthopaedic Trauma: November 2016 - Volume 30 - Issue - p S2-S6. https://doi.org/10.1097/BOT.0000000000000692
- Guo JJ, Tang N, Yang HL, et al. A prospective, randomized trial comparing closed intramedullary nailing with percutaneous plating in the treatment of distal metaphyseal fractures of the tibia. J Bone Joint Surg Br. 2010;92:984–988. https://doi.org/10.1302/0301-620X.92B7.22959
- Gardner, Michael J. MD In Displaced Distal Tibial Fractures, Intramedullary Nail and Locking Plate Fixation Did Not Differ in Terms of 6-Month Disability, The Journal of Bone and Joint Surgery: August 15, 2018 - Volume 100 - Issue 16 - p 1435. https://doi.org/10.2106/JBJS.18.00635
- Märdian S, Schwabe P, Schaser KD. Tibiaschaftfrakturen [Fractures of the tibial shaft]. Z Orthop Unfall. 2015;153(1):99-119. https://doi.org/10.1055/s-0033-1358089
- Morgan Laigle, Louis Rony, Raphaël Pinet, Romain Lancigu, Vincent Steiger, Laurent Hubert Enclouage centromedullaire des fractures ouvertes de jambes chez l’adulte. À propos de 85 cas. Revue de Chirurgie Orthopédique et Traumatologique, Volume 105, Issue 5, September 2019, Pages 649-653. Access: https://soo.com.fr/download/media/d08/d59/07-rony-louis.pdf.
- Effect of Locking Plate Fixation vs Intramedullary Nail Fixation on 6-Month Disability Among Adults With Displaced Fracture of the Distal Tibia: The UK FixDT Randomized Clinical Trial. JAMA. 2017;318(18):1767-1776. https://doi.org/10.1001/jama.2017.16429
- Metcalf KB, Brown CC, Barksdale EM 3rd, Wetzel RJ, Sontich JK, Ochenjele G. Clinical Outcomes After Intramedullary Nailing of Intraarticular Distal Tibial Fractures: A Retrospective Review. J Am Acad Orthop Surg Glob Res Rev. 2020;4(6):20.0008. Published 2020 Jun 10. https://doi.org/10.5435/JAAOSGlobal-D-20-00088
- Schemitsch EH, Bhandari M, Guyatt G, et al. Prognostic factors for predicting outcomes after intramedullary nailing of the tibia. J Bone Joint Surg Am. 2012;94(19):1786-1793. https://doi.org/10.2106/JBJS.J.01418
- Pramer A, Furner S, Rice DP. Musculoskeletal conditions in the United States. Park Ridge, ILL., AAOS 1992.
Table of Contents
- Close Femoral Incisions and Debride Tibial Fracture
- Locate Entry Point for Tibial Nail
- Insert Guide Wire
- Ream Tibia
- Insert Nail
- Place Traction Pin
Be on the other side. Pickups please. Scissors please. I don’t want to use those because they’ve been in that one. Try - I want to use fresh stuff over here. Okay - whatever. Can I have a 2-0? And I’d use a stapler here, I think. Staple. Yeah. We’re gonna use nylon for that traumatic wound and for the distal interlocks. Knee brace. Can I get a - a pair of scissors? Are these mine? Yes. So if someone asks how big of an incision you make, you say it exposes zone of injury. Some people would call this - it’s really not that comminuted; it’s a small thing, but it’s clearly high energy, but. How aggressive are you about taking out devitalized bone? If it’s really devitalized, I’ll take it out, but you know, if there’s any articular attachment or something like that, I’ll leave it. You know, if it’s a low grade open and it’s a very large piece...
They’re going to be in the unit. They’re coming back to the operating room. She’s going to be catabolic. I’d like to seal it up. Do you have another 2-0? None of this stuff here - I just don’t want to be holding any longer. It’s gonna be a little challenging to get this one reduced perfectly, but we’re gonna try our hardest. Okay.
Can we have a blue towel please? That looks like it’s pretty well reduced there. This piece may be blocking it a little bit, right? There - so you suck in there. Alright. Triangle. So another 30 minutes? No - 45 - we’re half done. 45? That was about an hour. We’ve got another hour. I think so. Blue marker please.
So hey - what do you think about the acute extremity compartment syndrome review? So, I’m - I just wrote a proposal with Dr. Varas. Oh, cool. So - so that’s basically including everybody - all of the - the trauma guys. I don’t know if it’s going to happen, but it’d be awesome. Oh yeah. That’s why I don’t want to overcommit to anything else right now because I want to see - yeah, you’ll want to do a good job on that one if you do. Yeah, kind of.
You just want to move that, don’t you? Just a little bit. You want to really be center - really be center. Alright, 10. And I’m pretty bold here. You’re going down to the - you’re going down, right? Here - the other way. There you go - cuz you want to go - cuz you want to go down right to the tibia. You can do it in two passes. So make the skin first - yep, there you go. And now - because you don’t want to saw the skin any. You want to go down. So it’s like that way.
What do you think about the different - I’m just gonna make a - suprapatellar or - I’m gonna make a... I like suprapatellar nailing. I - I do that for proximal and distal fractures. Good. What I want you to do is just take this and put it in there like that. Let's see. Maybe I can - just push it in like that. You want the knee flexed. You want to get it as far posterior as you can and then in line so that you’re right - right between my fingers there. Yep. Tap, tap, tap. So you just basically feel this in the middle, right? Yep. Keep going. Good. That’s good. And do you aim a little posterior or just? Just a tiny bit posterior. That looks pretty good, I think. Maybe a little lateral if anything, but we’ll get an X-ray and see.
How much have we done? 2. Yeah, we want 3 for the end - 3 for the end. Do you have any preference versus transpatellar, lateral? No real difference in knee pain, so I just go straight through it. It’s easier. You can make a smaller incision, and it’s a little faster. So why would you go lateral? Or medial. Some people do a medial parapatellar. Just – I think – the theor – theoretically, to avoid disrupting the patellar tendon. There’s - data shows no difference.
If you’re in the same hole and it’s not gonna give it to you, that’s fine. X-ray. Yep. That’s fine. So just make sure you’re aiming more medial - lot more medial. There you go. X-ray. Good. A little too much. Just be really careful. You’re - you’ve got a camera on your head, so you’ve got to be really careful. Yep. That’s fine. Yep. Good. X-ray. Good, so X-ray there. Save that. So that’s your ideal starting point. That looks really nice. Alright, let’s come around to a lateral. X-ray there. So that’s ideal. Save that. So that’s your ideal starting point. That’s really nice. Good job. So you’re right on the corner, right in front of the articular surface, and you’re just on the medial side of the lateral tibial spine, okay? So that’s perfect. Alright, so let’s open this up. X-ray there. I kind of find it’s nice if you drive that down a little bit because it – it – just - the – the wire’s really stiff. And so it kind of finds the canal, and it’s gonna make you be a little bit more in line with where you want to go. Okay, we’ll - we’ll put it on as soon as we go to a different view.
Just don’t hurt the skin. Trying to go towards you? Good. There you go, and then just right into bone. Braaah. Braaah. Just do it. Just go. Just right into the bone. Go. Push. Now come out. So - there you go like a trauma surgeon. Alright. Ball tip guidewire. Do you mind just grabbing the - light. Bring it down, so it just comes down a little bit. There you go. Perfect. So watch - watch your top - watch your top. 10 85 again? Yeah. Good. Alright – whoop. Come down to the fracture please. Good. X-ray there. Come down a little bit further. Yeah, this is pretty broken, but it’s not really stripped. I don’t know. 2, 3 A. X-ray. Alright, advance that. X-ray there. Keep going. Watch out. X-ray there. Shot. Try now. Good. X-ray. Come distal please. X-ray there. X-ray. Okay. X-ray there. X-ray there. So you’re aiming - we’ve got to get this out and put a little curve on it cuz you’re aiming a little bit medial there. Yep, so take this out. That’s me twisting the foot 90 degrees. Do you have a – do you have the bender? That’ll do it.
Now good – I’m good. Yeah, I don’t put a lot of bend in it - just a subtle bend - just enough to get it to go where you want. What would happen if it would go too medial? You end up getting a malalignment when you put your nail down. Tends to go in the varus. X-ray. X-ray. Or valgus. That looks good. X-ray. That’s – that’s out – that’s out, so pull it back. X-ray. Let’s try again. X-ray. That looks better. Keep going. X-ray. So get a - get a T handle on it so you can power it through there. That’s centered real nice though. I like that. X-ray there. Nicely. Okay. Mallet. Tap tap tap. Good. X-ray. So now turn it so it’s going a little more anterior. X-ray there. So that you’ve got to turn it 180. So you got to – no, no. Now you got to - 90. X-ray. Now it’s - X-ray. There you go. X-ray. There you go. Tap tap tap. X-ray. X-ray there. Tap, tap, tap. X-ray. X-ray there. Good. Tap, tap, tap. Just a little bit. Good. X-ray there. So that looks good there. That’s aiming right where I want it to. X-ray there. And now you’ve got to get it over the other way - so 180. There you go. X-ray. Good, so now tap, tap, tap. Yep – like you mean it. Good. X-ray. See that’s starting to go the right way?
And then let’s check this way. X-ray. That looks good there. X-ray there. Alright. Tap, tap, tap. X-ray. Little bit more. X-ray. And now hit it like you mean it. You really want it down? Yep. Alright, I think that’s probably okay. We could get it further, but I think it’s okay. Alright. X-ray there. X-ray. Alright, so we’re a little posterior, but I think that’s okay. X-ray. Come up to the knee please. What do you need now? Bigger hands. Alright, but what equipment do you want next? I want the ruler. The ruler please - yep. Ruler. Can we have the mallet back? So she’s got a pretty small canal, so we’re expecting a pretty small nail - probably about a 9. So we start by measuring so we know the length, and then as you ream, that determines your s – your diameter. X-ray there. That way. Yep, X-ray there. You got to get it in there a little bit. X-ray. Well, you can just measure it. So this says - so what do you want? 320? So they don’t come in 320s. No they don’t. So 300s plus 15 for a tibia, so this will be a 315. Yeah. Good. So 315. Alright, and then we’ll take an 8-5 and see what happens. Now if we can get to 10, that’d be great, but since we put a 9 in the femur, it’s hard to believe we’re gonna get to it. Sorry – 5.
Can you find out what nails we have? This is – it’s - what did we say? 315 by 8 and 315 by 9 are our options that we’re gonna use. So I want you to engage that in there first - yep. Just check and see if we have the tibial – the set in the cog – 315 by 8 and 315 by 9. Yeah, if you can bring those both in – yeah, thank you. The left - left, yep. Yep. Thank you. There’s no left and right! No, come south. Now here, I want you to be bringing it this way so you’re not hurting the skin, okay? Good. X-ray there. Good. Keep going. Keep going. Stop for a second. X-ray. Come up proximal. X-ray there. Alright, so let’s take that out, and we’re gonna have to use the flexible reamers. Don’t lose your wire. So hopefully we’ll have an 8, and then we only have to get to 9. What do you have for us? 7. 7. Alright, that’ll be a good start.
So it’s pretty rare, but sometimes your – you know, your standard reamer’s set to 8-5 as the incutting, but every so often, you’ve got a tight canal - you’ve got to start with one of the flexible reamers. Good. Good. Do we have an 8? I have an 8 by 315 and a 9 by 315. Let’s do an 8. Isn't that what you asked for? Yeah, we’ll do an 8. So, I thought you said, “a left.” It doesn’t matter. It doesn’t matter? It’s not – yeah, I was just messing with you. Sorry. I was wrong. I thought I was trying to find a right or a left. Yeah, sorry. I didn't mean to. Yeah, I mean, come on now. X-ray. Super cold. Is that an 8? Good. X-ray there. X-ray – what’s the most distal you can fix with the tibial nail? There's like a measurement like 1.5 something size of the scar. 2? 3? Was - it - it just kind of depends on your – it depends a lot on the fracture and the bone quality. That was 8. You want to go to 9? Yep, we’ve got to do 8-5 and then 9. So here’s your 8-5. How much irrigation do you need? A bazillion – six liters. We’ve lost very little blood. Is she opening the nail or running away? Woah – woah – woah. Come south. We’ve got to ream all the way down to the bottom now. Just come south. X-ray there. Okay. Good. X-ray. Nice. Keep going. Push hard. Push hard. What’s that? Push hard. Stop. X-ray there. Good.
Your wire is coming out, I think. X-ray. No, your wire is coming out. Mallet. There you go. Okay. You really got it? Yeah, I really got it. Spinning - no, it's spinning. Mallet. I can feel it spinning. You’ve just got to tap it - get that thing back down. Try backing out. X-ray there. So part of the problem is you’ve got to back this out first. Back it up a little bit first? Yep. Back it up a little bit first. Back it up please. Stop there. Now tap it down. There you go. That’s good. X-ray. There you go. 9 please. Okay.
Good. Good. Alright, we’ll take the nail. I like it. Blue. Tap, tap, tap. X-ray there. Good. X-ray there. Good. X-ray there. X-ray. Come up proximal just a tiny bit. X-ray there. Nice. Alright, good. Let’s come up to the knee. Get proximal a little bit – actually, X-ray there. Yeah, come proximal a little bit more. Raise your machine. X-ray there. X-ray there. Good, so you drove your nail down to a good depth. Come down to the ankle again. Let’s just make sure we’re happy with our depth there. X-ray there. X-ray. X-ray there. Okay, I think we’re pretty good. Let’s give it a - just a tiny bit more of a tap. That’s good. X-ray there. That’s nice. X-ray there. X-ray. X-ray. Can you hold the light knee for me? It’s kind of hard. X-ray. Now pull it back. Pull it back? X-ray. There you go. X-ray. Alright, so that’s reduced, so we’ve got to go a little bit further. Come up to the knee. Good. X-ray there. X-ray. Actually, that’s probably pretty good. X-ray. Yeah, I like that. We’re good.
Okay. Do you have a blue marker? Blue marker. No, we’re gonna close it, but we’re gonna put an incisional back on in. Okay. 15 please. Alright, a little guide. Mallet. Tap, tap. Good. Good reflex she had there. Yep. 32. Check - thank you. Okay, drill. Oops - just keep that in there. Drill. 34. Yep. Maybe even 36 actually. Acorn. Acorn. So that - once you pull it out, it actually reduces quite nicely there. And it’s kind of bone grafted itself there, so we’re gonna keep it in there. That’s the beauty of open fractures - is you can see it. Yep, that is correct. It’s like cheating.
Next time - you’d never know this, but I’d like a long one. Okay. Oh wait, no - I tried it, but it got like stuck in the head – like, I think, the long - does the long one work on that nail? Yeah – oh, I don’t know actually for a small one. Yeah. I don’t know. Yeah. X-ray there. Save that. So we have the nail driven down now. You can see it’s completely beneath the surface of the bone, which is what we’re looking for, but not too far down that if she has an infection or some problem, we can’t get it out. Come distal. And then the reason why - X-ray there. Keep coming distal. X-ray there. Save that. Come a little bit more distal. X-ray there. X-ray there. X-ray there. X-ray there. Save that. So that’s not bad. We’re in a tiny bit of recurve bottom but really not bad at all. And then let’s come up to an A-P. X-ray there. So I like our reduction. Come back towards you a little bit. X-ray. So the question now is just a matter of rotation, so our alignment is really nice in that plane. X-ray there. That looks really good. It’s just a matter of getting the – just perf – the reduction perfect. Do you have one more of these? Can you back out for a second? No, no - I need the room. Do you have a wheat-y? So one of the challenging things is to get rotation right. And so - sometimes you can use some of the fragments you have even though it’s not perfect reduction to get close. Good. X-ray there. Back out for a second. So we’re short. Yep, there we go. Now come back in. X-ray there. That’s pretty close. Back out again. Do you have a knife? Can you suck in here? Clinically, I agree. We like a little bit extra.
Can you turn the foot in for me? Yeah, there we go. No more, no more - less, less. Just real subtle. And I lost it. Just real subtle. Okay, suck. Now pull hard. Okay, come on in. Let go. Let’s just see how that looks, clinically. So clinically, it looks pretty good, so if we have the kneecap straight up, it looks pretty symmetric. Good. X-ray there. Let’s get rid of our clamp. Yep – or our thing. X-ray. X-ray. X-ray. Alright, let’s get a - give me a frog. So halfway towards you. Good. X-ray there. Good. Now go lateral. Oh - where’d our thing go? There. Rotate it in. X-ray there. That looks pretty good. Save that. Alright, so I like that rotation. Clinically, it looks good. Just a direct inspection – you know, it’s hard to cobble everything together perfectly, but everything seems to key together pretty nicely there. Once we have pointed reduction clamps, I’ll try to get it slightly better, and if – and we’ll take it. Is there any special technique that you would do if it was closed? Well, if it’s closed – well, that’s the advantage of having the other side of the field - is you get a cheat. You can get X-rays of the other side - AP and lateral of the knee - but it’s very, very hard. Really, the kind of trick I use the most is getting multiple planes - you know, the cortices should line up on all your X-rays.
X-ray there. X-ray. Alright, let’s come up to an AP. So it’s reasonable to expect that these will anatomically reduce because they weren’t anatomically reduced when we reamed, and even if they were, the reamer would have pushed them away. And so, the – the tibia is just – you know, it’s real tight, so it’s just not going to fit there. In a situation like this, we need lots of distal locking screws. So - come distal please. Do you have another couple towels? X-ray there. Can you arc over the top a tiny bit? X-ray there. X-ray there. That’s good. Knife please - 15. 15 please. P and the lateral have always looked good, so I’m not too worried. X-ray. X-ray. X-ray. X-ray. No. X-ray. My eyes aren’t that good - to see it with mag. No. Close though - close. But not - we’ve got kind of a large wound. We got a large wound. X-ray. X-ray. X-ray there. Depth gauge. X-ray. This depth gauge is so big. That sucks. I don’t know why there’s not a regular one. There isn’t a small fix at all. X-ray. I’m like pretty sure I drilled through that. Yep, there it is. Alright, here we go. 40. 44. X-ray. X-ray. Miss. It's been a while since I've done that. You – you don’t get to save that one. X-ray there. X-ray. X-ray. X-ray. X-ray. X-ray. May be in it now. No, I don’t think so. I – I think I missed it. I think I got it now though. X-ray. X-ray. X-ray. So that’s in there. Ankle feels fine. Okay. Yeah, I agree. Alright, irrigate – or X-ray. Good. Let’s get a lateral.
Knee in like that. X-ray there. X-ray there. X-ray there. Screwdriver. Yeah - mallet. We - we’ve got two more screws to put in. And right – yeah. X-ray there. Probably could be longer. That’s okay. 15 blade please. Come up – so internally rotate. Yeah – actually, come off lateral. That’ll help too. Actually, you can relax a little bit or just – yeah, there we go. Good. X-ray there. Come - can you wag south? Yep. Good. Now go north. Now pull back towards you. Good. Now go north. Now go up. It’s too far - subtle moves here please. Now go up - up. Good. X-ray there. Good. You’re off mag. Yeah. X-ray there. Come off lateral please. There you go. X-ray. There you go. Tiny bit, X-ray there. There it is. Raise your machine a tiny bit. Good. X-ray there. And then X-ray there. X-ray there. Can you come south just a tiny bit? X-ray there. Sorry, this is just getting late. X-ray. It’s lagging. X-ray there. X-ray there. Drill.
X-ray. X-ray. X-ray. X-ray. X-ray. Bullseye. Of all the places in the known universe for your hand to be, that’s the worst one. It’s just - you don’t want to be on the far side of the drill. Yeah, no - I know, but she has – she has Hep C. You don’t want to be – you don’t want to be anywhere near it. I don’t trust me. 36. Shot. What was this one we put in the front? The top? No, this last one we put in. 34. Are you sure? I thought it was like 40 something. Nah, it’s 34. Really? Yeah, pretty sure. Oh, it needs to be longer than that. That’s gonna be a 38. No wonder it’s so short. Alright.
X-ray. I like to take a picture before I drive it home, so I still have access to the screw head to confirm that I’m right on target. That’s a nice bite there. Good. 15. Do they have those sure shot things and all that? X-ray. Nah. X-ray. Once you get pretty fast though with perfect circles… Little vein there. X-ray there. Nope. You got to internally rotate. X-ray. X-ray there. X-ray there. A tiny bit more proximal. X-ray there. And it doesn’t really give you that much, I don’t think. 40. 40? Yep. You know, that maybe took a minute. Don’t seem worth it.
X-ray. But I think if you’re a low frequency surgeon, I think maybe there’s some utility to it, but if you’re doing a lot of these, it doesn’t really. You get pretty used to it quickly. Well, I think it’s designed for people in the community. Yeah. Do you have a small? Well maybe she is dislocated, or she just has a really boney ankle. What’s that? Oh yeah. Come south for me. Yeah, you’re right – behind the knot right there. X-ray there. Yeah. Internally rotate a little bit. X-ray there. And that looks normal. That looks okay. Let’s get an oblique of the foot to be sure, but I think it’s okay. Yeah, it’s the same. It’s just – that’s just her - she’s just flexible. She’s just flexible.
Can I have a Freer? It’s that anterior-medial border of the tibia. You know, that’s a nice flat surface of bone, and there’s that. You know, that’s pretty - pretty similar. You know, it doesn’t seem like we’re turned in or out or - there’s the crest right there - there’s the crest right there. They’re lined up pretty well. I think we’re pretty good. I think we’re within 5 to 10 degrees, which is good. So you can always perseverate on it because it’s a - especially with a malaligned one, it’s easy to mess it up, but. Alright why don’t we - let’s get our final X-rays, and then what I want to do is get AP of the knees and make - get – make APs of the knees. Oh yeah, screwdriver. We’ll see in a minute. We’re gonna see. Can you measure this and give me 6 longer? No. Yeah, I hear you man. X-ray. Can you lift up? X-ray there. X-ray. Can you come to an AP? X-ray. X-ray. Screwdriver. X-ray. X-ray there. X-ray there. Alright, will you come up to the knees please. You know, radiographically, I’m a little concerned about it. It’s okay but not perfect. About the ankle or about the knee? The – the rotation, yeah. X-ray there. Can you swap that for me? Come prox – come back towards you.
X-ray there. X-ray there. X-ray there. X-ray there. That’s actually pretty similar - maybe a few degrees out but definitely not far. X-ray there. X-ray there. X-ray there. X-ray there. X-ray there. There. There. Well, no - I mean, you got to get the rotation right. Yeah. I think that’s pretty good. I think I’m happy there. Okay. Raise the table for us, please? You want higher? That’s good. Show me the knee, please. Push in, please. Push in, please. There you go. X-ray. X-ray there. Can you just make that straight up and down for me? Just one quick over - the other way. One more click. Good. Save that. Come south. Keep coming south. Good. X-ray there. X-ray there. Pull back towards you a little bit. Yep. X-ray there. Come south. So those screws are a little long, but I think they’re going to be okay. Yep. X-ray there. Now that one’s too long. What a hassle. Alright, screwdriver. Go north. Take off 4, I guess. The distal one’s okay.
There you go. Yep. She’s moving around a lot today. Good. Alright, come on south again. Show me the fracture. Come up proximal a little bit. X-ray there. X-ray there. X-ray there. X-ray there. Can you straighten that up for us - just rotate it around? One click or two? The other way. One more. Back a bit. Back one. Back one click. There you go. X-ray. X-ray. X-ray. Save that. X-ray. X-ray. Save that. Come to a lateral, please. Come back up. X-ray there. Can you drop the table for us please? Good. X-ray there. X-ray there. X-ray. Save that. Come up proximal a little bit. X-ray. Now trumpet. X-ray. Save that. Come up towards the knee please. X-ray. Save that.
Alright, one last thing - I want to see this. Come down to the ankle. Come south even further. X-ray there. X-ray there. Alright, so to get a lateral, I got to really twist it in, so that just makes sense. Come up to the knee. There. X-ray there. Yeah. X-ray there. So it’s the same. X-ray there. She’s just got a lot – she’s like me. She’s got a lot of external tibia torsion. Okay. Good. Alright, thank you. Come on out. We are done with X-ray. Irrigation please. We got that 3 liters up, right? No traction pin. Well, actually, show me the - I don’t think so. Show me the hip again – the right hip. Turn in there. X-ray. X-ray. Come south. Back towards you. There you go. X-ray there. X-ray. X-ray. X-ray. X-ray. Just hold it reduced like that, huh? X-ray. X-ray. Yeah, we can put her in 15 pounds of traction - won’t hurt anything. Just make sure you’re down here. I think it’s fine. We’ll do that. Whoever called us about the traction bow, can you say, “Yes, we need it?” Alright, basin.
One pin - a traction pin. Alright, so why don’t you get sewing up there? Get that – get that up. To do a – to do a perfect tibial traction pin, you go from the fibular head and go basically – do you go from the tibial tuber - so if you go Gerdy’s tubercle to tibial tubercle, you can go like this, and that creates a safe arc. So it creates an arc. Yeah, like – like this. So the ideal pin would be like right there. Yeah, just a little distal over there. You could probably be - maybe a little bit – little bit – more distal? Yeah, right about in there.
Do we have some local? Alright, I will take the nylon – or the vicryl. 2-0? 2-0, yeah. Can I have a knife please? Half percent with epi – do you care? What’s up? For local? No. Half percent with epi. Sure. Sure, we can use half percent here. Half percent what? Marcaine. Mar - yeah, Marcaine. Thank you. Schnidt please. Knife back. You said with - with epi? Yep. That’d be great. Do we have the cart open? There's some scissors out. Alright, get some scissors. There’s some scissors out. Scissors? Scissors? Scissors? I need some too. Do you have the drill with the – yeah, it’s coming. So now it’s just gonna be a tibial traction pin, and then we’re done. Now we’re just gonna do a tibial traction pin and then close up, and then we’re done. Okay. Can I have the – can I have the quick chuck stuff? Do you mind just me chucking up on this? Take it off the… Sure. It would be a lot faster. Sure. Are you guys – are they coming tomorrow? You guys coming tomorrow? Yeah. Alright, can we do the stuff tomorrow? The talking? Yeah, absolutely. If you – if you agree to do the tibial nail in the morning, first thing. Otherwise, we’ll have some difficulties with one of our team members here. Thank you.
Can we have some – do we - are we getting some local? So then you feel for the anterior border? And the posterior border? Yep. Find the middle. And then you split the difference. Just don’t get in the fibula. That would be bad. It’s been done. Can you get me – do we have a bolt cutter? I – I want that extra pin that’s in there. That’s mine. I want you to take a bolt cutter. We're gonna need bolt cutter - and cut off the tip, and I want this. Okay. And where do you usually like to aim at? Can I have a 2-0? Parallel. There you go. Knife please. Knife back.
So that remear closeup came for her. I’ll have them leave the traction on. Non-weight-bearing on the right side – Schnidt - and weight-bearing on the left. Leave her on this though? Not going to waver at all? Transfer only. For a while? Alright. Nada. When do you want me to have them – them make your interview – to come back here? Monday. Same for Monday? Nah, it’s okay – it’s okay. It was later in the week. And later on for planning of the multiple femur as well as ORIF of the acetabular. The coed will probably be per neurosurg. Yeah. We should recommend a filter.
So you want to – to cut it a little bit? What’s up? Do you want to cut the – the… That should actually be quite okay, right? Do you want me to cut it that off? Yeah. Can we get a bolt cutter? Yeah. Hopefully before Christmas – do you have the… Okay, Mark, thank you. That was good. That was good. Can I see the bone? So we’re coming in with X-ray.
Alright, final picture time. Voshte, open the CR, bro. Voshte - come here! You’re the CR man. Voshte, push it - I need another 2-0 please. Voshte, did you shave your mustache? So next time – no - come up here - yeah. Do I do it again? No. Cuz now you’re completely useless cuz you don’t have a mustache. Yeah, that’s a little posterior. As long as it’s enough on bone and blank article. Annika, another 2-0 please?
Do you want to go to the lateral or finish up first? Save that. Go to lateral, yeah. X-ray. Save that. Nice shot, man! Looks good. I actually like it. I think that’s perfect. I thought maybe you were a little posterior, but I think you’re absolutely perfect. It looked – it just looks a little posterior. Good job. Throw this behind you - throw this behind you. Nylon? Coming up.