Intramedullary Nail for Open Tibial Fracture
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Pickups please. Scissors please. I don’t want to use those because they’ve been in that one. I want to use fresh stuff over here. Can we have a 2-0? And I’d use a stapler here I think. Staple. Yeah. We’re going to use nylon for that traumatic wound, and for the distal interlocks. Can I get a pair of scissors? Are these mine? Yes. So when someone asks how big of an incision to make you say to expose the zone of injury. Some people would call this -- it’s really not that common, it’s a small thing. But it’s clearly high energy. How aggressive are you about taking out devitalized bone? If it’s really devitalized, I’ll take it out. But if there’s any articular attachment or something like that, I’ll leave it. Or 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. It’s going to be a little challenging to get this one reduced perfectly, but we’re going to 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, see it? Alright. Triangle. So another 30 minutes? No, we’re half done. 45. That was about an hour, we’ve got another hour. I think so. Blue marker please.
What do you think about acute extremity compartment syndrome review? I just wrote a proposal with Dr. Varas. Oh, cool. So that’s basically including everybody, all 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 want to do a good job on that one. 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. I’m pretty bold here. You’re going down, right? Here, the other way. There you go, because 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, because you don’t want to saw the skin. You want to go down. So it’s like, that way.
What do you think about the different, suprapatellar or --. I like suprapatellar nailing I do that for proximal and distal fractures. Good. What we’re going to do is just take this, and put it in there like that. 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 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 posterior? Just a tiny bit posterior. Looks pretty good, I think. Maybe a little lateral if anything, but we’ll get an X-ray.
How much have we done? 2. Yeah we want 3 for the end. Do you have any preference? Transpatellar or 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? Medial. Some people do a medial parapatellar theoretically to avoid disrupting the patellar tendon. Data shows no difference.
If you’re in the same hole and it’s not giving it to you, that’s fine. X-ray. Yeah, that’s fine. Just make sure you’re aiming more medial. A lot more medial. There you go. X-ray. Good. Too much. Just be careful, you’ve got a camera on your head so you’ve got to be really careful. Yep that’s fine. 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. 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. 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 the wire is really stiff and so it finds the canal and its going to make you be a little bit more in line with where you want to go. Okay we’ll put it on as soon as we go to a different view.
Just don’t hurt the skin. There you go. Good, and just right in the bone. Just do it. Just go. Just right into the bone. Push. Now come out. There you go, like a trauma surgeon. Alright. Ball tip guidewire. Watch your top, watch your top. Yep. Good. 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. 2-3a. X-ray. ALright advance that. X-ray there. Keep going. Watch out. X-ray there. 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. Because you’re aiming a little bit medial there. Yep so take this out. That’s me twisting the foot 90 degrees. Do you have the bender?
I’m good. Don’t put a lot of bend on it, just a subtle bend. Just enough to get it to go where you want. You end up getting a malalignment when you put your nail down. Tends to go in the varice. X-ray. That looks good. X-ray. That’s out so pull it back. X-ray. Try it again. X-ray. That looks better. X-ray. Get a T handle on it so you can power it through there. That centered real nice there, 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 you’ve got to turn it 180. No now 90. X-ray. X-ray. There you go. X-ray. There you go. Tap tap tap. X-ray. X-ray there. Tap tap tap. Just a little bit. Good. X-ray there. 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. Good. X-ray. See that’s starting to go the right way.
And then lets check this way. 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. 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 it’s ok. X-ray. Come up to the knee please. What do you need now? Bigger hands. But what equipment do you need? I want the ruler. Ruler please, yep. Here’s 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 diameter. X-ray there. That way. Yep X-ray there. Yeah you got it in there a little bit. X-ray. You can just measure it. So this is -- so what do you want? 320? So they don’t come in 320s. 300s plus 15 for a tibia so this will be a 315, yeah. 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 its hard to believe we’re going to get to it.
Can you find out what nails we have? This is, what did we say? 315 by 8 and 315 by 9 are our options we’re going to use. So I want you to engage that in there first, yep. Yeah if you can bring those both in, thank you. Left, yep. There’s no left and right. No, come south. No here, I want you to bring 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 going to 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. Alright that’ll be a good start.
So it’s pretty rare, but sometimes your standard reamer set to 8-5 is your standard 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 15 and a 9 by 15. Let’s do an 8. Yeah, we’ll do an 8. Yeah, I mean come on now. X-ray. Super cold. Is that an 8? Good. X-ray there. It just kind of depends a lot on the fracture and the bone quality. We’ve got to do 8-5 and then 9. Here’s your 8-5. A bazillion. 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 to the bottom now. Just come south. X-ray there. Good. X-ray. Nice. Keep going. Push hard. Stop. X-ray there. Good.
Your wire is coming out. X-ray. Yeah your wire is coming out. Mallet. 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 it 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 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, it’s kind of hard. Now pull it back. Pull it back? X-ray. X-ray. Now 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 going to close it, but we’re going to put an incision in. 15 please. Alright, a little guide. Mallet. Tap tap. Good. Good reflex she had there. 32. Check, thank you. Okay, drill. Oops, keep that in there. Drill. 34. Yep. Maybe even 36 actually. Acorn. Acorn. So once you pull it out, it actually reduces quite nicely there. And it’s kind of bone grafted itself there, so we’ll keep it in there. That’s the beauty of about open fractures is you can see it. Yep that’s correct. It’s like cheating.
Next time, you’d never know this, but I’d like a long one. Okay. No, I tried it but it got stuck on the nail, like I think does the long one work on the nail? Yeah, oh I don’t know actually for a small one. 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 something that we can’t get it out. Come distal. 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. That’s not bad, we’re a tiny bit weaker bottom but 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 just getting the reduction perfect. Do you have one more of these? Can you back out for a second? No, no I need that. Do you have a weedy? So one of the challenging things is to get rotation right. Sometimes you can use some of the fragments you had even though it’s not perfect reduction, to get close. X-ray there. Back out for a second. We’re short. Yep there we go. Now come back in. X-ray there. That’s pretty close. Back out again. You have a knife? Can you suck in here? Clinically I agree.
Can you turn the foot in for me? Yeah, there we go. No more, no more, less, less. Just really subtle. Ah I lost it. Just real subtle. 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 knee cap straight up, it looks pretty symmetric. X-ray there. Let’s get rid of our clamp. X-ray. X-ray. X-ray. Alright let’s get a, get me a frog. Halfway towards you. Good. X-ray there. Good. Now go lateral. Where’d our thing go? There. Rotate a bit. X-ray there. That looks pretty good. Save that. Alright so I like that rotation, clinically it looks good. Just in a direct inspection, it’s hard to cobble everything together perfectly but everything seems to key together pretty nicely there. Once we have point reduction clamps we can try to get it slightly better. We’ll take it. Well that’s the advantage of having the other side of the field is you get to cheat. You can get X-rays of the other side, A-P and lateral of the knee but it’s very hard. Really the trick I use 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 A-P. So it’s reasonable to expect that these will anatomically reduce because when we anatomically reduced when they were reamed, and even if they were the reamer would have pushed them away. And so the tibia is just real tight, so it’s not going to fit there. In a situation like this we need lots of distal locking screws. 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 always look 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 have a large wound. X-ray. X-ray. X-ray there. Depth gauge. X-ray. This depth gauge is so big. That sucks it isn’t a regular one. There is in there though. I like where your head's at! X-ray. I’m pretty sure I drilled through that. Yep there it is. Alright here we go. 40. 44. X-ray. X-ray. Miss. You don’t get to save that one. X-ray there. X-ray. X-ray. X-ray. X-ray. X-ray. Maybe in it now. No I don’t think so. I think I missed it, I think I got it now. X-ray. X-ray. X-ray. So that’s in there. Ankle feels fine. Okay. Irrigate. X-ray. Good let’s get a lateral.
Knee in like that. X-ray there. X-ray there. X-ray there. Screwdriver. Mallet. We’ve got two more screws to put in. X-ray there. Probably could be longer. That’s ok. 15 blade please. Come up, internally rotate. Come off lateral too, that’ll will help. You can relax a little, yeah there we go. X-ray there. Can you wax out? Yep. Good. Now go north. Now pull back towards you. Good. Now go north. Now go up. 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 there. 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. You don’t want to be on the far side of the drill. Yeah no, I know but she has hep-C, 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. You sure I thought it was like 40 something. Really? Yeah pretty sure. It needs to be longer than that. That’s going to 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. Yeah they have those sure shot things and all that. X-ray. X-ray. Once you get pretty with perfect circles. X-ray there. Nope internally rotate. X-ray. X-ray there. X-ray there. A tiny bit more proximal. X-ray there. It doesn’t really give you that much, I don’t think. 40. Yep. Yeah that maybe took a minute. Don’t seem worth it.
X-ray. 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 you get pretty used to it quickly. I think it’s designed for people in the community. Yeah. Get me the small. Oh maybe she is dislocated. Or she has a really boney ankle. What’s that? Come south for me. Yeah you’re right. X-ray there. Yeah. Internally rotate a little bit. Ah 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. She’s just flexible, she’s just flexible.
Can I have a freer? It’s that anterior-medial border of the tibia, that’s a nice flat surface of bone and there’s that. That’s pretty, pretty similar. 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 5-10 degrees which is good. So you can always perseverate on it because especially with an accommodated one it’s easy to mess it up, but. Alright why don’t we, let’s get our final X-rays and get A-Ps of the knees. Get A-Ps of the knees. Oh yeah, screwdriver. We’ll see in a minute. We’re going to see. Can you measure this and give me 6 longer? Yep. Yeah I hear you. X-ray. X-ray now. X-ray. Can you come to an A-P? X-ray. X-ray. Screwdriver. X-ray. X-ray there. X-ray there. Alright will you come up to the knees please? Radiographically I’m a little concerned about it, it’s okay but not perfect. About the ankle or the knee? The rotation, yeah. X-ray there. Can you swap that for me? 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. That’s pretty good. I think I’m happy there. Raise the table for us, please? 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 quick. 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. You’re really 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 out a little bit for us, just rotate 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. I’m going to come 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. 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, that 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 like me she’s got a lot of external torsion. Okay. Good. Alright thank you, come on out. We are done with X-ray. Irrigation please. We got that 3 liter stuff right? No traction pin. Well actually show me the -- I don’t think so -- show me the hip again. 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. Hold it reduced like that. 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. 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 up. So to do a perfect tibial traction pin, you go from the fibular head to the basically -- so if you go Gerdy’s tubercle to tibial tubercle you go like this, and that creates a safe arc. So it creates an arc, yeah like this. So the ideal pin would be like right there. Yeah, distal to distal. You could probably be a little bit, yeah right about in there.
Do we have some local? Alright I will take the vicryl. 2-0 yeah. Can I have a knife please? What’s up? For the local. 5% with epi? Sure. Do we have the cart open? There’s some scissors out. Can I have some scissors? Scissors? Scissors? I need some too. Do you have the drill with the --. So now we’re just going to do a tibial traction pin, close up, and we’re done. Are they coming tomorrow? You guys coming tomorrow? Can we do the stuff tomorrow? The talking? Yeah, absolutely. Yeah 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.
Are we getting some local? So then you feel for the anterior border? And then the posterior border? 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 a bolt cutter. I want that extra pin that’s in there, that’s mine. I want you to take a bolt cutter, take it off the tip, and I want this. Okay. And where do you usually like to aim at? Parallel. There you go. Knife please.
Transfer only. A while? Alright. Monday. We should recommend a filter. That should be quite okay right? Do you want me to cut that off? Yeah. Get a bolt cutter? Yeah. Hey Mark thank you. That’s good. That’s good. We’re coming in with X-ray. Alright final picture time. Voshte come here, you’re the CR man. I need another 2-0 please. Voshte, did you shave your mustache? No. So next time -- come up here, right? Yeah. No. Yeah, more posterior. As long as it’s enough on bottom, Annika another 2-0 please?
Do you want to go to lateral? Save that. Go to lateral, yeah. X-ray. Save that. Nice shot, man! Looks good. I actually like it, looks perfect. I thought maybe you were a little posterior but you’re absolutely perfect. It just looks a little posterior. It’s behind you, behind you. Nylon? Coming up.
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