Executive Editor: Peter Trafton

Authors: Raymond White, Matthew Camuso

Tibial shaft Multifragmentary fracture, intact segmental - Intramedullary nailing

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Immediate postoperative care

Immediately after surgery, while the patient is still in the hospital, emphasis is given to

  • Pain control
  • Mobilization
  • Infection and deep veinous thrombosis (DVT) prophylaxis
  • Early recognition of complications

Compartment syndrome occasionally develops after IM nailing. During the first day after nailing, sensation and strength should be followed carefully. Increasing pain may be a warning sign.

The patient’s leg should be slightly elevated, with the leg placed on a pillow, approximately 4 cm above the level of the heart. This maintains perfusion while helping to avoid swelling.

Soft-tissue protection

A brief period of splintage may be beneficial for protection of the soft tissues, but should last no longer than 1-2 weeks. Thereafter, mobilization of the ankle and subtalar joints should be encouraged.


Encourage active motion of all joints (hip, knee, ankle, and toes). Gentle, progressive stretching to achieve knee extension and ankle / foot dorsiflexion begins as soon as tolerated.

Weight bearing

Partial weight bearing with crutches is started as soon as the patient is able. Unrestricted weight bearing should be delayed until fracture callus is visible, fibular healing is evident, and weight bearing is without pain.

Follow up

Clinical and radiological follow-up is recommended after 2, 6 and 12 weeks. Depending on the consolidation, weight bearing can usually be increased after 6-8 weeks, with full weight bearing when the fracture has healed.

Implant removal

Implant removal may be necessary in cases of soft-tissue irritation by the implants. The best time for nail removal is after complete remodeling, usually at least 12 months after surgery.
Locking screws may need to be removed sooner if they are prominent and/or painful. Once callus is evident, such screws are usually unnecessary, but individual assessment is necessary to avoid premature screw removal, with late loss of fracture alignment.

In this case, 12 weeks after nailing the fibula was bridge-plated for additional stability.

v2.0 2012-05-13