Tales from Telford- II

A common fracture encountered in the middle to old aged patients is fracture of the distal tibia with associated fracture of the proximal fibula. The fracture configuration depends on the type of fracturing force applied. A direct blow produces a traanverse fracture, whereas an indirect blow causes a oblique fracture. Rotational injury causes spiral fractures.

Tranverse fractures can generally be managed conservatively in cast. However, if the patient is young fit and healthy Internal fixation can be opted for in the form of IM nailing since they load bearing devices. Load sharing devices are not suitable for these fractures due to lack of strength. The patient would have to be followed up regularly in clinic with Xray on arrival to check the position of fracture.

Oblique fractures , as a rule, reduce as easily as transverse fractures, but it is difficult to maintain reduction.Hence, internal fixation is necessary. Spiral fractures on the other hand are difficult to reduce and maintain in required position.

With regards to internal fixation, the preferred method is Intramedullary nailing. There i salso the possibility of use of Plates and screws, but since they are "load sharing" devices their role is minimal.

For an IM nailing procedure. There are minor points to lo0k into prior to the operation, which can help make the operation absolutely smooth. Otherwise even putting a screw incan be a pain in the arse.

Make sure the the patient supports are put in completely once before the patient arrives and dismantle it to get the patient on. Once the affected leg is placed on the support make sure the arse is pushed in as close to teh heel as possible. This helps to expose the point for incision/ entry adequately.
The incision/ point of entry of guide wire is on the little flat surface that starts just anterior to the anterior surface of the kbnee joint capsule and blends into the tibial tuberosity. The patellar tendon can be cut through.
When the guide wire is passed make sure you visualize it going through the fracture point. Make sure you dont touch the guide wire to the ceiling/ lamps. The guide wire will have to be changed with the help of an exchange tube and then the nail is passed over the guide wire. It is important that the top end of the nail is flush with the bony surface and not jutting out. bloody pain in the arse later on. get the proximal and distal interlocking screws in. one of the proximal ones will be a dynamic screw. so important to get it in right.
Close the entry points with ethilon, after u have visualizedf the nail in toto beyond the fracture site. opsite/ wool/ crepe.
to agar aap ke ghar main koi tibia toota ho...to tibial nail zaroor lagaae!!