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Maintaining reduction during unreamed nailing of a segmental tibial fracture: the use of a Farabeuf clamp
Injury, Int. J. Care Injured 34 (2003) 389–391
Technical note
Maintaining reduction during unreamed nailing of a segmental tibial fracture: the use of a Farabeuf clamp A. Robertson, P.V. Giannoudis, S.J. Matthews∗ Department of Trauma and Orthopaedics, St James’s University Hospital, Beckett Street, Leeds LS9 7TF, UK Accepted 25 October 2001
1. Introduction The treatment of segmental tibial fractures remains technically challenging for the surgeon and difficulties may often be encountered intra-operatively, principally in maintaining reduction and ensuring good alignment of the fracture ends, while minimising soft tissue disruption. We report on the use of the Farabeuf reduction clamp as a useful aid in maintaining reduction of a closed segmental tibial fracture during unreamed intramedullary fixation.
The thickness of the cortex was measured and the proximal cortex tapped. Screws corresponding to the thickness of the cortex with the addition of 4 mm to the length were inserted while ensuring that the screw ends did not significantly breach the medullary cavity, thereby impeding the passage of the intramedullary nail (Fig. 3). Reduction was obtained and maintained using the Farabeuf reduction forceps (Fig. 4). The 8 mm solid tibial nail was then passed in the usual manner. Following full insertion and locking of the intramedullary device, the reduction screws were removed. Post-operative films demonstrated reduction of the central segment (Fig. 5).
2. Case history An 88-year-old male was admitted with an isolated, closed segmental tibial fracture following a road traffic accident (Fig. 1). Clinical examination revealed no distal neuro-vascular compromise. Six hours following the admission, he underwent stabilisation of the fracture with an unreamed tibial nail. Pre-operatively the canal diameter was measured to be 9 mm. The entry point was prepared and the intramedullary canal opened with hand reamers. During the insertion of an 8 mm solid tibial nail, distraction of the proximal segmental fracture was encountered (Fig. 2). The Farabeuf clamp was then used to maintain reduction while the nail was passed.
3. Procedure A short incision was made over the fracture line. Minimal dissection allowed removal of interposed soft tissues and permitted visualisation of the bone ends. Unicortical, longitudinally aligned drill holes were made with the 2.5 mm drill between 1 and 2 cm on either side of the fracture line. ∗ Corresponding author. Tel.:+44-113-2433144; fax: +44-113-2065156. E-mail address: [email protected] (S.J. Matthews).
4. Discussion The current consensus of fracture management favors, minimally invasive osteosynthesis techniques, in order to reduce soft tissue compromise and prevent devascularization of the bone fragments [1]. This philosophy is especially important in cases with extensive soft tissue injury. Segmental tibial fractures in particular are often associated with high energy transfer, severe soft tissue injury and periosteal stripping resulting in significant impairment of the blood supply to the central segment. The method of stabilisation of these fractures remains contentious with results often being unsatisfactory [2]. Most authors, however, agree that internal fixation using intramedullary nailing [3] with the use of interlocking bolts has resulted in improved outcomes [4]. The use of unreamed intramedullary nails has gained favor as a result of its relative preservation of endosteal blood supply and minimal disturbance of the soft tissue envelope [5]. When the bone ends are extensively exposed (Gustillo grade 3a/3b) direct reduction is often possible. However, in closed injuries and those with minimal soft tissue damage (Gustillo grade 1 and 2) reduction simply by passage of the
0020-1383/03/$ – see front matter © 2003 Elsevier Science Ltd. All rights reserved. PII: S 0 0 2 0 - 1 3 8 3 ( 0 1 ) 0 0 1 9 5 - 4
390
A. Robertson et al. / Injury, Int. J. Care Injured 34 (2003) 389–391
Fig. 3. Screw placement.
Fig. 1. Pre-operative radiograph.
intramedullary nail may be difficult. Distraction often occurs between the proximal and central segments as the remaining soft tissues poorly maintain the position of the central segment. Reduction of the distal segment then becomes difficult as a result of surrounding tissue tension. Previously described methods to aid reduction and to prevent this distraction include the use of percutaneous stab incisions and the application of large pointed reduction forceps [6]. Matthews et al. describe the temporary application of unicortical plates, which may then be left in situ to enhance fracture stability and inhibit mal-alignment [7]. Control of alignment is often difficult with the first method due to inadequate purchase of the pointed ends of the reduction forceps and the latter method can result in unnecessary stripping of the soft tissues and periosteum, further denuding the bone ends of their blood supply. The method described provides a simple, minimally invasive method for holding reduction at the proximal fracture line. The conversion of a closed to an open fracture in
Fig. 2. Distraction between proximal and central fragments.
A. Robertson et al. / Injury, Int. J. Care Injured 34 (2003) 389–391
391
Fig. 4. Farabeuf clamp maintaining reduction.
the controlled environment of the operating theatre is, we believe, justifiable in order to aid reduction, if the overlying soft tissue is healthy. We believe, this method gives good control of alignment and prevents distraction facilitating the passage of an intramedullary device while minimising disruption to the periosteal blood supply.
References
Fig. 5. Post-operative radiograph.
[1] Farouk O, Krettek C, Miclau T, et al. Minimally invasive plate osteosynthesis and vascularity. Injury 1997;28(Suppl 1):SA7–12. [2] Melis GC, Sotgiu F, Lepori M, Guido P. Intramedullary nailing in segmental tibial fractures. J Bone Joint Surg (Am) 1981;63: 1310–8. [3] Zucman J, Maurer P. Two-level fractures of the tibia. Results in thirty-six cases treated by blind nailing. J Bone Joint Surg 1969;51B:686–93. [4] Ekeland A, Thoresen BO, Alho A, Stromsoe K, Folleras G, Haukebo A. Interlocking intramedullary nailing in the treatment of tibial fractures: a report of 45 cases. Clin Orthop 1988;231:205–15. [5] Huang CK, Chen WM, Chen TH, Lo WH. Segmental tibial fractures treated with interlocking nails. A retrospective study of 33 cases Acta Orthop Scand 1997;68(6):563–6. [6] Ruedi TP, Murphy WM, editors. AO principles of fracture management, Thieme, 2000. [7] Matthews DE, McGuire R, Freeland AE. Anterior unicortical buttress plating in conjunction with an undreamed interlocking intramedullary nail for treatment of very proximal tibial diaphyseal fractures. Orthopaedics 1997;20:647–8.
Technical note
Maintaining reduction during unreamed nailing of a segmental tibial fracture: the use of a Farabeuf clamp A. Robertson, P.V. Giannoudis, S.J. Matthews∗ Department of Trauma and Orthopaedics, St James’s University Hospital, Beckett Street, Leeds LS9 7TF, UK Accepted 25 October 2001
1. Introduction The treatment of segmental tibial fractures remains technically challenging for the surgeon and difficulties may often be encountered intra-operatively, principally in maintaining reduction and ensuring good alignment of the fracture ends, while minimising soft tissue disruption. We report on the use of the Farabeuf reduction clamp as a useful aid in maintaining reduction of a closed segmental tibial fracture during unreamed intramedullary fixation.
The thickness of the cortex was measured and the proximal cortex tapped. Screws corresponding to the thickness of the cortex with the addition of 4 mm to the length were inserted while ensuring that the screw ends did not significantly breach the medullary cavity, thereby impeding the passage of the intramedullary nail (Fig. 3). Reduction was obtained and maintained using the Farabeuf reduction forceps (Fig. 4). The 8 mm solid tibial nail was then passed in the usual manner. Following full insertion and locking of the intramedullary device, the reduction screws were removed. Post-operative films demonstrated reduction of the central segment (Fig. 5).
2. Case history An 88-year-old male was admitted with an isolated, closed segmental tibial fracture following a road traffic accident (Fig. 1). Clinical examination revealed no distal neuro-vascular compromise. Six hours following the admission, he underwent stabilisation of the fracture with an unreamed tibial nail. Pre-operatively the canal diameter was measured to be 9 mm. The entry point was prepared and the intramedullary canal opened with hand reamers. During the insertion of an 8 mm solid tibial nail, distraction of the proximal segmental fracture was encountered (Fig. 2). The Farabeuf clamp was then used to maintain reduction while the nail was passed.
3. Procedure A short incision was made over the fracture line. Minimal dissection allowed removal of interposed soft tissues and permitted visualisation of the bone ends. Unicortical, longitudinally aligned drill holes were made with the 2.5 mm drill between 1 and 2 cm on either side of the fracture line. ∗ Corresponding author. Tel.:+44-113-2433144; fax: +44-113-2065156. E-mail address: [email protected] (S.J. Matthews).
4. Discussion The current consensus of fracture management favors, minimally invasive osteosynthesis techniques, in order to reduce soft tissue compromise and prevent devascularization of the bone fragments [1]. This philosophy is especially important in cases with extensive soft tissue injury. Segmental tibial fractures in particular are often associated with high energy transfer, severe soft tissue injury and periosteal stripping resulting in significant impairment of the blood supply to the central segment. The method of stabilisation of these fractures remains contentious with results often being unsatisfactory [2]. Most authors, however, agree that internal fixation using intramedullary nailing [3] with the use of interlocking bolts has resulted in improved outcomes [4]. The use of unreamed intramedullary nails has gained favor as a result of its relative preservation of endosteal blood supply and minimal disturbance of the soft tissue envelope [5]. When the bone ends are extensively exposed (Gustillo grade 3a/3b) direct reduction is often possible. However, in closed injuries and those with minimal soft tissue damage (Gustillo grade 1 and 2) reduction simply by passage of the
0020-1383/03/$ – see front matter © 2003 Elsevier Science Ltd. All rights reserved. PII: S 0 0 2 0 - 1 3 8 3 ( 0 1 ) 0 0 1 9 5 - 4
390
A. Robertson et al. / Injury, Int. J. Care Injured 34 (2003) 389–391
Fig. 3. Screw placement.
Fig. 1. Pre-operative radiograph.
intramedullary nail may be difficult. Distraction often occurs between the proximal and central segments as the remaining soft tissues poorly maintain the position of the central segment. Reduction of the distal segment then becomes difficult as a result of surrounding tissue tension. Previously described methods to aid reduction and to prevent this distraction include the use of percutaneous stab incisions and the application of large pointed reduction forceps [6]. Matthews et al. describe the temporary application of unicortical plates, which may then be left in situ to enhance fracture stability and inhibit mal-alignment [7]. Control of alignment is often difficult with the first method due to inadequate purchase of the pointed ends of the reduction forceps and the latter method can result in unnecessary stripping of the soft tissues and periosteum, further denuding the bone ends of their blood supply. The method described provides a simple, minimally invasive method for holding reduction at the proximal fracture line. The conversion of a closed to an open fracture in
Fig. 2. Distraction between proximal and central fragments.
A. Robertson et al. / Injury, Int. J. Care Injured 34 (2003) 389–391
391
Fig. 4. Farabeuf clamp maintaining reduction.
the controlled environment of the operating theatre is, we believe, justifiable in order to aid reduction, if the overlying soft tissue is healthy. We believe, this method gives good control of alignment and prevents distraction facilitating the passage of an intramedullary device while minimising disruption to the periosteal blood supply.
References
Fig. 5. Post-operative radiograph.
[1] Farouk O, Krettek C, Miclau T, et al. Minimally invasive plate osteosynthesis and vascularity. Injury 1997;28(Suppl 1):SA7–12. [2] Melis GC, Sotgiu F, Lepori M, Guido P. Intramedullary nailing in segmental tibial fractures. J Bone Joint Surg (Am) 1981;63: 1310–8. [3] Zucman J, Maurer P. Two-level fractures of the tibia. Results in thirty-six cases treated by blind nailing. J Bone Joint Surg 1969;51B:686–93. [4] Ekeland A, Thoresen BO, Alho A, Stromsoe K, Folleras G, Haukebo A. Interlocking intramedullary nailing in the treatment of tibial fractures: a report of 45 cases. Clin Orthop 1988;231:205–15. [5] Huang CK, Chen WM, Chen TH, Lo WH. Segmental tibial fractures treated with interlocking nails. A retrospective study of 33 cases Acta Orthop Scand 1997;68(6):563–6. [6] Ruedi TP, Murphy WM, editors. AO principles of fracture management, Thieme, 2000. [7] Matthews DE, McGuire R, Freeland AE. Anterior unicortical buttress plating in conjunction with an undreamed interlocking intramedullary nail for treatment of very proximal tibial diaphyseal fractures. Orthopaedics 1997;20:647–8.