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Patient positioning for closed locked tibial nailing
Injury (1990) 21, 193
Printed in Great Britain
193
Ideas and Innovations
Patient positioning
for closed locked tibia1 nailing
R. A. Hill and J. S. Albert Department
of Orthopaedics,
Norfolk and Norwich
Hospital, Norwich,
Closed locked tibia1 nailing is facilitated by accurate reduction of the fracture and careful positioning of the patient before surgery commences. The prerequisites for success~l nailing are discussed.
Whilst many tibia1 shaft fractures can be treated satisfactorily by conservative means, the unstable tibial fracture presents considerable difficulties in management. The ideal fracture fixation system maintains length and rotational and angular alignment of the fractured bone, whilst allowing immediate mobilization of the associated joints and early weight bearing where appropriate. These requirements can be met by a locked intramedullary nail, and this method of fixation has become more popular in the operative manage-
Figure I. Patient positioned for right tibia1 nailing. 0 1990 Butterworth-Heinemann 0020-1383/90/030193~2
Ltd
UK
ment of the unstable tibia. (Werry et al., 1985; Cross and Montgomery, 1987). The tibia has a poor periosteal blood supply and, as a result, open procedures are associated with a relatively high infection and non-union rate. Closed nailing has been shown to have a lower infection rate than open naiiing (Bone and Johnson, 1986), and also preserves the soft tissue envelope and the fracture haematoma. The procedure is technically demanding, but its advantages make it the operative treatment of choice. There are a number of prerequisites for successful closed nailing:I. The leg must be held by a suitable traction system that will maintain the fvacture in the reduced position.
Figure 2. Image intensifier access.
194
Injury: the British Journal of Accident Surgery (1990) Vol. 2l/No.
3
We have found that traction is most easily and securely applied via an OS calcis pin that is removed at the end of the procedure. One of the advantages of this method is that with the foot and ankle visible it is much easier to check rotational alignment during fracture reduction. In addition, the tibia can be completely exposed during surgery to permit the very distal insertion of locking screws, If traction is applied via a boot exposure may be inadequate.
A traction system that meets these requirements is illustrated in Figure I and Figure 2. The other leg is positioned in such a way that there is free access for both the surgeon and image intensifier. Positioning of the patient and accurate reduction of the fracture are crucial to the success of closed nailing and should be considered an integral part of the procedure.
2. There musf be unimpeded access fo the whole of the fibia and fhe knee for fhe surgeon and the image intensifier.
Acknowledgement
Although reaming and nail insertion are carried out from the lateral side of the patient, locking screws are usually inserted from the medial side of the tibia to avoid the fibula. Static locking is generally advised in acute fractures (Henley, 1989), to prevent shortening and to control rotation. The traction system used must therefore allow the surgeon free access to both sides of the limb. 3. The fhigh should be supported without pressure on fhe poplifeaf fossa in such a way that fhe knee can be flexed to at least 90”. Adequate flexion is necessary to allow the passage of the guidewire and nail down the medullary canal without impinging on the posterior cortex or the patella. If the knee is inadequately flexed there is also a tendency for the entry point to be made far too anteriorly, and there is then a risk of the nail breaking out of the anterior cortex during insertion. Care should be taken to avoid pressure on the neurovascular bundle - the support should be placed under the distal femur rather than in the popliteal fossa.
The traction system illustrated was developed at the Norfolk and Norwich Hospital with the skilful assistance of the Physics Workshop.
References Bone L. B. and Johnson K. D. (1986) Treatment of tibial fractures by reaming and intramedullary nailing. J. Bone Joing Stlrg. 68A, 877. Cross A. and Montgomery R. J. (1987) The treatment of tibia1 shaft fractures by the interlocking medul1zu-y nail system 1. Bone Joint Surg. 69B, 489. Henley M. B. (1989) Intramedullary devices for tibia1 fracture stabilisation. C&r. Orfhop. 240, 87. Weny D. G., Boyle M. R., Meek R. N. et al. (1985) Intramedullary fixation of tibia1 shaft fractures with A0 and Grosse-Kempf locking nails: a review of 70 consecutive fractures. 1. Bone Joint Surg. 67B, 325.
4. If should be possible to adjust the fracfion during fhe procedure. Occasionally reduction is lost during the operation and it is helpful if the traction can be adjusted by an assistant without disturbing the sterile field. Impaction of non-comminuted fractures is usually advisable as a degree of distraction occurs during nail insertion. The traction must be released before this is done.
Erratum R. Vaishya, A thorny problem: the diagnosis and treatment of acacia thorn injuries, Injury (IWO) 21, 97-100 The published version of Figure 4 was incorrect. The correct version should have been:
Thorn /16) Total (22)
removed \
Immediately ~;;>wi$a;;d~“rs
patients interval
\ Not removed (Osteomyelitis) -surgery (6)
The publishers apologise for this error.
After 24 hours (Synovitisl -surgery (4)
Paper accepted
8 December
1989.
Requestsfor reprints should be addressed to: Mr J. S. Albert, Department of Orthopaedics, Norfolk and Norwich Brunswick Road, Norwich NRI 3SR, UK.
Hospital,
Printed in Great Britain
193
Ideas and Innovations
Patient positioning
for closed locked tibia1 nailing
R. A. Hill and J. S. Albert Department
of Orthopaedics,
Norfolk and Norwich
Hospital, Norwich,
Closed locked tibia1 nailing is facilitated by accurate reduction of the fracture and careful positioning of the patient before surgery commences. The prerequisites for success~l nailing are discussed.
Whilst many tibia1 shaft fractures can be treated satisfactorily by conservative means, the unstable tibial fracture presents considerable difficulties in management. The ideal fracture fixation system maintains length and rotational and angular alignment of the fractured bone, whilst allowing immediate mobilization of the associated joints and early weight bearing where appropriate. These requirements can be met by a locked intramedullary nail, and this method of fixation has become more popular in the operative manage-
Figure I. Patient positioned for right tibia1 nailing. 0 1990 Butterworth-Heinemann 0020-1383/90/030193~2
Ltd
UK
ment of the unstable tibia. (Werry et al., 1985; Cross and Montgomery, 1987). The tibia has a poor periosteal blood supply and, as a result, open procedures are associated with a relatively high infection and non-union rate. Closed nailing has been shown to have a lower infection rate than open naiiing (Bone and Johnson, 1986), and also preserves the soft tissue envelope and the fracture haematoma. The procedure is technically demanding, but its advantages make it the operative treatment of choice. There are a number of prerequisites for successful closed nailing:I. The leg must be held by a suitable traction system that will maintain the fvacture in the reduced position.
Figure 2. Image intensifier access.
194
Injury: the British Journal of Accident Surgery (1990) Vol. 2l/No.
3
We have found that traction is most easily and securely applied via an OS calcis pin that is removed at the end of the procedure. One of the advantages of this method is that with the foot and ankle visible it is much easier to check rotational alignment during fracture reduction. In addition, the tibia can be completely exposed during surgery to permit the very distal insertion of locking screws, If traction is applied via a boot exposure may be inadequate.
A traction system that meets these requirements is illustrated in Figure I and Figure 2. The other leg is positioned in such a way that there is free access for both the surgeon and image intensifier. Positioning of the patient and accurate reduction of the fracture are crucial to the success of closed nailing and should be considered an integral part of the procedure.
2. There musf be unimpeded access fo the whole of the fibia and fhe knee for fhe surgeon and the image intensifier.
Acknowledgement
Although reaming and nail insertion are carried out from the lateral side of the patient, locking screws are usually inserted from the medial side of the tibia to avoid the fibula. Static locking is generally advised in acute fractures (Henley, 1989), to prevent shortening and to control rotation. The traction system used must therefore allow the surgeon free access to both sides of the limb. 3. The fhigh should be supported without pressure on fhe poplifeaf fossa in such a way that fhe knee can be flexed to at least 90”. Adequate flexion is necessary to allow the passage of the guidewire and nail down the medullary canal without impinging on the posterior cortex or the patella. If the knee is inadequately flexed there is also a tendency for the entry point to be made far too anteriorly, and there is then a risk of the nail breaking out of the anterior cortex during insertion. Care should be taken to avoid pressure on the neurovascular bundle - the support should be placed under the distal femur rather than in the popliteal fossa.
The traction system illustrated was developed at the Norfolk and Norwich Hospital with the skilful assistance of the Physics Workshop.
References Bone L. B. and Johnson K. D. (1986) Treatment of tibial fractures by reaming and intramedullary nailing. J. Bone Joing Stlrg. 68A, 877. Cross A. and Montgomery R. J. (1987) The treatment of tibia1 shaft fractures by the interlocking medul1zu-y nail system 1. Bone Joint Surg. 69B, 489. Henley M. B. (1989) Intramedullary devices for tibia1 fracture stabilisation. C&r. Orfhop. 240, 87. Weny D. G., Boyle M. R., Meek R. N. et al. (1985) Intramedullary fixation of tibia1 shaft fractures with A0 and Grosse-Kempf locking nails: a review of 70 consecutive fractures. 1. Bone Joint Surg. 67B, 325.
4. If should be possible to adjust the fracfion during fhe procedure. Occasionally reduction is lost during the operation and it is helpful if the traction can be adjusted by an assistant without disturbing the sterile field. Impaction of non-comminuted fractures is usually advisable as a degree of distraction occurs during nail insertion. The traction must be released before this is done.
Erratum R. Vaishya, A thorny problem: the diagnosis and treatment of acacia thorn injuries, Injury (IWO) 21, 97-100 The published version of Figure 4 was incorrect. The correct version should have been:
Thorn /16) Total (22)
removed \
Immediately ~;;>wi$a;;d~“rs
patients interval
\ Not removed (Osteomyelitis) -surgery (6)
The publishers apologise for this error.
After 24 hours (Synovitisl -surgery (4)
Paper accepted
8 December
1989.
Requestsfor reprints should be addressed to: Mr J. S. Albert, Department of Orthopaedics, Norfolk and Norwich Brunswick Road, Norwich NRI 3SR, UK.
Hospital,