A Outpatient Evaluation and Management 1 Obtains focused history and performs focused exam need to check wounds for evidence of open fracture assess lower extremity compartments document distal neurovascular status check for associated orthopedic injuries 2 Interpret basic imaging studies interpret biplanar radiographs of entire tibia/fibula, knee, and ankle obtain CT scan with distal 1/3 fractures (high rate of posterior malleolar fractures) proximal third fractures (joint line extension) 3 Prescribe and manage nonoperative treatment acceptable alignment for closed tibia fractures <5° varus/valgus, <10° anterior/posterior, >50% cortical apposition, <1cm shortening, <10° rotation can be placed into long leg cast and then a functional brace at 4 weeks 4 Makes informed decision to proceed with operative treatment describes accepted indications and contraindications for surgical intervention 5 Provides post-operative management and rehabilitation postop: 2-3 week postoperative visit wound check staples/sutures removed continue physical therapy and range of motion exercises repeat radiographs of tibia diagnose and management of early complications<br /> repeat xrays of tibia postop: ~ 3 month postoperative visit diagnosis and management of late complications<br /> repeat xrays of tibia postop: 1 year postoperative visit repeat xrays of tibia B Advanced Evaluation and Management 1 Prioritizes the needs of the polytrauma patient timing of long bone fixation works with consulting 2 Order and interpret advanced imaging studies 3 Complex wound management and debridement understanding need for consultation for flap coverage 4 Capable of treating complications both intraoperatively and post-operatively manages post operative infection C Preoperative History and Physical 1 Obtain history and perform basic physical exam assess lower extremity compartments document distal neurovascular status 2 Order basic imaging studies need biplanar radiographs of entire tibia/fibula, knee, and ankle 3 Perform operative consent describe complications of surgery including post-operative knee pain symptomatic prominent interlocking screws malunion nonunion malrotation compartment syndrome superficial/deep infection
E Preoperative Plan 1 Template fracture reduction draw key fragments of fracture and plan the forces required to obtain the reduction 2 Template instrumentation measure diameter of the intramedullary canal and approximate length 3 Execute surgical walkthrough describe key steps of the procedure to the attending verbally prior to the start of the case describe potential complications and the steps to avoid them F Room Preparation 1 Surgical instrumentation make sure tibia intramedullary nailing system is present before the start of the case 2 Room setup and equipment radiolucent OR table optional large sharp periarticular clamps or Weber-style clamps large external fixation system or femoral distractor c-arm fluoroscopy c-arm from contralateral side, perpendicular to bed 3 Patient positioning patient supine with feet at the end of the bed, small bump under ipsilateral thigh need to move all lights away from area directly over OR table as this will get in the way of guidewires and reamers step stool to get better angle for reaming prep and drape with full access to foot and ankle to judge intraoperative length, rotation, and alignment G Parapatellar Knee Approach 1 Plan out anterior approach to knee options include medial parapatellar (most common, described below) lateral parapatellar patellar tendon splitting suprapatellar approach in cases of decreased knee flexion, can also use suprapatellar approach through superolateral aspect of patella incision and approach are made ~4cm proximal to the superior edge of the patella 2 Position leg on triangle and make incision flex knee over radiolucent triangle mark out inferior pole of patella, borders of patellar tendon, joint line, tibial tubercle make incision from inferior pole of patella distally 2.5cm towards tibial tubercle along medial 1/3 of patellar tendon 3 Spread down to dissect paratenon identify medial edge of patellar tendon and incise retract patellar tendon laterally insert self-retaining retractor use a Gelpi to maintain access H Starting Point and Guidewire Insertion 1 Identify guidewire starting point just medial to the lateral tibial spine on the AP radiograph on anterior cortical downslope on lateral view 2 Open canal with starting point reamer use cannulated starting point reamer to open canal (drill to metaphyseal bone) 3 Insert guidepin guidepin should be placed parallel with canal on AP view and just posterior to parallel on lateral view 4 Advance guidewire proximal to fracture site place balltip guidewire in canal with T-handle place gentle bend at tip of wire I Fracture Reduction and Reaming 1 Fracture reduction traction technique reduce fracture by pulling traction over triangle can use small blue towel bump behind leg as a bump use mallet to hold pressure over fracture site can use intramedullary finger reduction tool and/or pointed reduction clamps through skin incisions traveling box technique If working alone or with untrained assistant, or if reduction assistance is needed, apply traveling “box” traction before knee incision can use femoral distractor over pins as an alternate to external fixator bars insert pins through posterior distal tibia (or calcaneous) and posterior proximal tibia (just anterior to fibular head but in posterior proximal tibia) 2 Advance guidewire once fracture reduced, manually push guidewire past fracture site to distal physeal scar 3 Check biplanar imaging to ensure wire is in canal 4 Measure nail length with ruler make sure guidewire is seated at physeal scar 5 Start with size 9mm reamer, then ream up 0.5-1.0mm with each reamer push down through starting hole into bone before starting reamer this prevents eccentric reaming of your starting point can use step stool to get better body position for reaming if needed check chatter from reamer feedback and diaphyseal fit on C-arm imaging minimal to no reaming at fracture site to minimize eccentric reaming ream 1.0mm above size of final nail (i.e. size 12mm reamer head for size 11mm nail) If a distal fracture, don't ream the distal tibia unless the guidewire is in perfect position J Nail Insertion with Alignment Techniques (blocking screws) 1 Obtain proper alignment blocking screw technique when coronal or sagittal malalignment is noted, blocking screws are placed on the concavity of the deformity place posterior or lateral to the guide wire in the proximal segment in proximal 1/3 fractures these screws serve as a pseudo-cortex to guide the nail and increase stiffness of the construct 2 Assemble nail build nail on backtable and make sure targeting guide lines up with holes in nail 3 Manually advance nail insert nail over guidewire and push into place manually as much as possible advance to fracture site and minimize mallet use at fracture site to minimize iatrogenic comminution insert nail fully and check lateral C-arm view at the knee to ensure the nail is sunk at or below the edge of the bone 4 Check alignment and rotation check that rotation of the nail is aligned with 2nd metatarsal if compression is needed across fracture site, insert distal interlocking screws via perfect circles technique then backslap distal fragment into proximal fragment must sink nail into proximal segment enough to allow backslapping 5 Remove guidewire K Proximal Interlocking Screws 1 Place trochar onto bone attach proximal targeting guide and mark skin with triple sleeves for 2-3 static holes use a 15 blade through skin, spread down to bone with hemostat, place trochar of sleeve on bone 2 Place interlocking screw remove inner sleeve then drill through 1st cortex when hitting 2nd cortex, stop and measure, call out length, then finish 2nd cortex (2nd cortex adds 2-5mm) remove inner sleeve and insert screw be careful not to over tighten screws as they can sink into bone easily in metaphyseal bone 3 Repeat process above for placement of other interlocking screws if indicated can lock screws proximally into nail if the instrumentation allows 4 Remove targeting guide and jig from nail L Distal Interlocking Screws 1 Obtain perfect circles bring the knee into full extension and lay entire leg on sterile bumps move to distal tibia and get perfect circles of interlock screws ensure no rotation of the distal tibia is done while getting the fluoroscopic views (move the C-arm, not the leg) magnification of fluoro (x2) can be used if desired, but is not necessary 2 Drill holes for interlocking screws use a 15 blade scalpel to locate the nailhole on medial distal tibia, and incise through skin spread down to bone with hemostat place drill in hole, then center drill parallel to xray beam drill toward center of C-arm beam do not stop drill when bit at nail unless progress halted by eccentric drilling if drilling is off, take drill off bit and leave bit in drilled hole recenter the bit on fluoroscopy and use a mallet to drive it across the nail holes this force may cause malalignment in distal fractures 3 Place interlocking screws measure the depth with a depth gauge or with calibrated drill bit remove drill quickly and insert screw repeat above process for 2nd distal interlocking screw have more freedom to move the limb for fluoroscopy after first screw placed 4 Obtain biplanar fluroscopic images of the proximal, middle, and distal tibia 5 Check limb length, rotation, alignment, and perform a knee ligamentous examination N Wound Closure 1 Irrigation, hemostasis, and drain strongly flush out reamings from knee with saline bulb irrigation irrigate until backflow is clear cauterize peripheral bleeding vessels 2 Tissue Closure patellar tendon splitting close patellar tendon and paratenon layers with 0-Vicryl subcutaneous layered closure with 3-0 Vicryl skin closure with staples or suture medial parapatellar close parapatellar arthrotomy, subcutaneous and skin closure 3 Dressings soft incision dressings over knee and distal tibia ACE wrap from distal thigh to toes to help with edema
O Perioperative Inpatient Management 1 Write comprehensive admission orders serial compartment checks x 24 hours advance diet as tolerated pain control wound management remove dressings POD2 foley out when ambulating check appropriate labs antibiotics prescribe DVT prophyhlaxis 2 Check radiographs in postop check placement of hardware 3 Initiate Physical Therapy POD 1 weight-bearing as tolerated immediate range of motion exercises to knee 4 Appropriate medical management and medical consultation 5 Discharges patient appropriately pain meds outpatient PT schedule follow-up in 2 weeks wound care R Complex Patient Care 1 Develops unique, complex post-operative management plans