Executive Editor: Peter Trafton

Authors: Theerachai Apivatthakakul, Surapong Anuraklekha, George Babikian, Fabio Castelli, Antonio Pace, Vajara Phiphobmongkol, Raymond White, Kodi Kojima, Matthew Camuso

Tibial shaft 42-A1 ORIF

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Glossary

1 Principles top

Bending, shearing and torsional forces may cause screw loosening enlarge

Indications

Nonoperative treatment

Spiral fractures of the tibial diaphysis can be treated nonoperatively. However, some shortening must be expected. The initial x-ray usually shows the expected final shortening. Displacement of more than 30%, particularly for distal fractures, suggests an increased risk of secondary displacement with nonoperative treatment.

Malrotation is a risk which must be looked for and corrected, particularly during the first weeks of nonoperative treatment.

Operative treatment with a nail
Nailing is usually a good option in tibial fractures. However, in long spiral fractures, malrotation can be a problem and must be addressed by the surgeon.


Operative treatment with lag screws and protection plate
For the treatment of simple spiral fractures in the diaphyseal area, absolute stability is recommended. For this, anatomical reduction and interfragmentary compression are necessary. Interfragmentary compression is achieved with at least two lag screws, but the strength of this fixation is often insufficient for clinical use.

Protection plate
Bending, shearing and torsional forces acting on an unprotected lag screw may cause screw loosening, loss of compression, or fracture of the bone. In order to protect the lag screw from these forces, a protection plate should be applied.

2 Preoperative planning top

Screw position enlarge

Screw position

Lag screws should always be inserted as perpendicular as possible to the fracture plane where they cross it.

Lag screws inserted through a plate give better stability than screws outside of a plate. Whenever possible, plan the plate position so that one or two screws can be inserted through the plate and still perpendicular to the fracture.
However, in some situations, one, or both, lag screws have to be inserted outside of the plate, depending on fracture geometry and surgical access.


Plate location enlarge

Plate location

If the anteromedial skin is completely free of injury, a plate can be positioned on this tibial surface. When in doubt about the soft tissues, an anterolateral plate may have less risk of wound breakdown.
An anteromedial, subcutaneous plate does not require muscle elevation, as would be necessary anterolaterally, but with some loss of periosteal blood supply. Furthermore, this location also allows a more distal position of the plate.

The plate should be long enough to span the fracture zone, usually with at least 3 screws proximal and distal.
A narrow, large-fragment (4.5 mm screws) plate is usually chosen. It will need to be bent and twisted to fit the selected tibial surface.

3 Open reduction top

Open reduction enlarge

Introduction

Open, or direct, reduction is necessary to achieve the required anatomical reduction.

Leave the periosteum on the bone, except elevate just enough around the fracture edges to confirm the reduction.

Pointed reduction forceps are preferred because they do less damage to the soft tissues.


Manual traction enlarge

Reduction

In a first step, length and rotation must be restored. This may be possible with manual traction. Otherwise, mechanical aids such as a large distractor, or bone spreader, should be considered.


Reduction of the fracture enlarge

In a second step, once length and rotation are restored, pointed reduction forceps are used to compress and anatomically reduce the fracture. The forceps tips should be applied perpendicular to the plane of the fracture, just like a lag screw.

4 Preparation top

Assessing the fracture plane enlarge

Introduction

Sometimes the fracture is in a plane that makes it impossible to insert the lag screws through the plate perpendicularly to the fracture plane. In such cases, the lag screws are inserted outside of the plate. Depending upon fracture location and soft-tissue condition, the plate is then applied to either the anteromedial, or the anterolateral surface.


Provisional fixation enlarge

Provisional fixation with the pointed reduction forceps

Use the pointed reduction forceps to provisionally stabilize the fracture. Select a position for the forceps that will not interfere with the planned position of the screws, or plate.

Remember, the forceps can be placed either medially or laterally. Choose the position that allows the most stability with the least soft-tissue damage.

5 Drilling and tapping top

Drilling the gliding hol enlarge

Gliding hole for the first lag screw

Using a 4.5 mm drill guide and a 4.5 mm drill bit, drill a gliding hole in the near cortex.

Ensure that the direction of the drill is as perpendicular to the fracture plane as possible.


Drilling the thread hole enlarge

Drilling the thread hole

Insert the 4.5 mm / 3.2 mm drill into the gliding hole. Use a 3.2 mm drill bit to drill a thread hole just through the far cortex.


Countersinking in diaphyseal bone enlarge

Countersinking in diaphyseal bone

There are two important reasons for countersinking:

  1. Countersinking ensures that the screw head has a maximal contact area with the bone, so that its compressive forces are widely distributed.
  2. A countersunk screw head is less prominent and tender.

No countersinking in the metaphysis enlarge

No countersinking in the metaphysis

Do not countersink the screws in the metaphysis as its cortex is very thin.

Countersinking through a thin cortex removes the bone surface on which the screw head must rest. Instead, a washer should be considered.


Measuring for screw length enlarge

Measure for screw length

Use a depth gauge to measure for screw length.

Measure the longer side of an oblique drill hole, as shown, to ensure sufficient screw length.

A screw should protrude 1-2 mm through the opposite cortex to ensure thread purchase. However, too long a screw may be tender, or injure soft tissues.


Tapping the thread hole enlarge

Tap the thread hole

Use a 4.5 mm tap and the corresponding drill sleeve to tap the thread hole.

6 Screw insertion top

Lag screw insertion enlarge

Lag screw insertion

Insert the first lag screw and carefully tighten it. Ensure that the fracture remains reduced, and is compressed.


Insertion of the second lag screw enlarge

Insertion of the second lag screw

Insert the second lag screw following the same steps as for the first lag screw:

  1. Drill the gliding hole with a 4.5 mm drill bit and drill guide as perpendicular to the fracture plane as possible.
  2. Insert the 4.5 mm / 3.2 mm drill guide into the gliding hole.
  3. Drill the thread hole with a 3.2 mm drill bit.
  4. Countersink the near cortex.
  5. Measure for length.
  6. Tap the thread hole with a 4.5 mm tap.
  7. Insert the screw.

 

7 Plate placement top

Plate selection and preparation enlarge

Plate selection and preparation

The correct length of the straight 4.5 mm DCP should allow at least 3 screw holes proximal and 3 screw holes distal of the fracture site.

Usually a 10-12 hole straight 4.5 mm DCP is used. The plate has to be twisted and bent to perfectly adapt to the shape of the anteromedial distal tibia.


Insertion of diaphyseal plate screws enlarge

Insertion of diaphyseal plate screws

The screws closest to the fracture zone are inserted first. Insert the remaining screws alternately, working your way outwards. Remember that it is not necessary to fill every screw hole, but those closest to and furthest from the fracture must be used.

For all diaphyseal screws, use cortical screws, observing the following steps:

  1. Drill both cortices using the appropriate drill guide to ensure a central drill hole with the 3.2 mm drill bit.
  2. Measure for screw length.
  3. Tap both cortices using the 4.5 mm tap and appropriate drill sleeve.
  4. Insert the screw.

Insertion of metaphyseal plate screws enlarge

Insertion of metaphyseal plate screws

In the metaphysis, use screws with cancellous threads.

Observe the following steps:

  1. Drill using the appropriate DCP drill guide to ensure a central drill hole with the 3.2 mm drill bit. Do not penetrate the far cortex (or the joint).
  2. Measure for screw length.
  3. Tap just the near cortex using the 6.5 mm tap and appropriate drill sleeve.
  4. Insert cancellous screws and carefully tighten them.

Metaphyseal screws should be as long as possible but must not penetrate the far cortex, or the joint.

v2.0 2012-05-13