Minimally invasive intramedullary nail fixation of tibia
Authors: Zhang Haibo, Zhang Qing, Wang Yisheng
【Abstract】 Objective] To sum up type C2 fracture of tibia clinical characteristics, Minimally invasive intramedullary nail fixation of tibia fractures C2 and efficacy of surgical method. [Method] since May 2000 ~ March 2006 adoption of minimally invasive intramedullary nail fixation of C2 fracture of tibia of 30 cases, male 21 cases and 9 females; aged 20 to 63 years old, with an average 41.5 years of age. 14 cases of closed fractures using the finite-reamed intramedullary nail treatment; open fractures
of 16 cases (including Gustilo ? and ?) use of non-reamed intramedullary nail
treatment, both static nature of the fixed. Injury from the operation time was 2h ~ 12 d, an average of 4.5 d. [Results] The average follow-up time was 16.5 months (7 ~ 21
months). Each contributed 30 cases of bone healing, fracture healing time was 4 to 9 months, an average of 6.2 months. According to Johner
small-leg compartment syndrome, deep infection, knee pain, the main nail and nail breakage and malunion occurred. 2 cases of delayed healing. [Conclusion] C2 fracture
of tibia more than damage caused by the high-energy, multi-occur in the backbone
area. Minimally invasive intramedullary nail fixation is the treatment of tibial fractures C2 a better way, its simple operation, surgical trauma, fixed and reliable, high rate of
fracture healing, less complications and results were satisfactory. Norms and minimally invasive surgical operation should be a high priority.
Key words tibial fractures; fracture fixation; intramedullary; minimally invasive; treatment outcome
C2 fracture of tibia multi-segment shall tibial fractures, for the clinical complexity of the more common type of fracture of the tibia. Treatment of tibial fractures in the general methods such as cast immobilization, calcaneal traction, internal fixation, etc.,
if used in the treatment of such injuries due to have a high rate of fracture nonunion, and many other complications, have been locked intramedullary nail replaced by . Minimally invasive treatment of orthopedic technology for the changing pattern of the
fracture, that is fixed to the bio-mechanics biological changes in the concept of
minimally invasive fixation , it is minimally invasive technology to become a real advantage to play a locked intramedullary nail the key. Ignore the minimally invasive
operation, may be due to an increase of iatrogenic trauma to affect the overall efficacy of interlocking intramedullary nail. Since May 2000 ~ March 2006, the Court adopted minimally invasive intramedullary nail fixation of tibia fractures of C2-type 30 cases,
good curative effect, the report is as follows:
A clinical data and methods
1.1 General Information
The group of 30 cases, male 21 cases and 9 females; aged 20 to 63 years old, with an average 41.5 years of age. Injuries reasons: traffic injuries in 14 cases, weight砸伤9
cases, height fall injury in 4 cases, roller rolling injury in 2 cases, a fall in 1 case. Closed fracture in 14 cases; 16 cases of open fractures, open fractures according to Gustilo
classification: Gustilo ? type in 7 cases, Gustilo ? type in 9 cases. Tibia is
anatomically divided into six zones  (Figure 1): A District (shin bone area): mostly trabecular bone, cortical bone is thinner, is located around the knee; B District (tibial
tubercle area) : cortical bone and cancellous bone at the junction, there is more muscle attachment, thicker periosteum; C zone (proximal the middle of the backbone area): cortical bone, there are nourishing vascular access; D region (the middle of the
backbone area): cortical bone, a single of the intramedullary blood supply; E region (distal the middle of the backbone area): cortical bone and cancellous bone junction; F area (ankle on the area): cancellous bone, a thin cortex, located around the joint.
Fracture the fracture line in the above position based on the distribution of various partitioning: B ~ C zone 1 cases, B ~ D Area 2 cases, C ~ D Zone 13 cases, C ~ E Zone 9 cases, D ~ E Zone 2 cases, the above There are a medial segment of bone; B ~ D ~ E
District 1 case, C ~ D ~ E Zone 2 cases of the above there are two inside the bone segments. Accompanied by fibula fracture in 24 cases, 6 cases of complete fibula. Associated with other fractures in 7 cases, chest and abdominal trauma in 4 cases, 3
cases of brain trauma. Are fresh fractures, injuries from the operation time was 2 h ~ 12 d, an average of 4.5 d.
Line vertical incision in the middle of patellar tendon at 1 cm below the tibial plateau bone at open holes. If the fracture segment easy reduction, percutaneous
fixation with a fixed clamp segment and the maintenance of fracture reduction; if their difficulties in fracture reduction, then the fracture line at the small incision, so that fracture segment to achieve anatomic reduction and temporary fixation with fracture reduction clamp. Closed fractures were reamed with limited technical and non-reamed
open fracture techniques, ascending into the intramedullary nail. In the C-arm X-ray
machine, adjust the perspective of the spaces and intramedullary nail fracture location. Install sight and has a fixed distance side-locking nail (Figure 2 ~ 3).
Figure 1 Schematic diagram of tibial anatomic area (omitted)
Figure 2-type C2 fracture of the tibia is preoperative lateral X-ray films
Figure 3 Postoperative lateral X-ray films are (abbreviated)
1.3 Postoperative management
After Taigaohuanzhi. 1 d after the first of encouraging patients with quadriceps and calf triceps isometric exercise; crutches after 2 weeks may be Fu Shimoji, but the limb should be under the protection of leg braces to allow only toe-point land; generally a
gradual increase after 6 weeks partial weight bearing, regular film shows a gradual increase after the formation of bone callus weight-bearing.
Follow-up 7 ~ 21 months, an average of 16.5 months. In all cases covering a bone healing, fracture healing time of 4 to 9 months, an average of 6.2 months. The final functional evaluation according to Johner
syndrome (osteofascial compartment syndrome, OCS), deep infection, knee pain, the main nail and nail breakage and malunion occurred. 2 cases of delayed healing, healing
time was 8.5,9 months.
C2 fracture of tibia 3.1 The clinical characteristics of
(1) Multi-trauma caused by the high-energy, is often associated with local soft tissue contusion; (2) fractures occurred in many parts of the backbone area (ie, C, D, E area), this group of 26 cases, accounting for 86.7%; (3) than any other The main types of tibial fractures with different points in its complete ring fracture of the medial segment blocks, of which there is a fracture of the medial segment of the main block, this group of 27 cases, accounting for 90%; (4) Although the treatment of more many, but its interlocking intramedullary nailing for fracture healing can provide a good biological environment obvious advantages, has become the treatment of tibial fracture-C
preferred. Reposted elsewhere in the paper for free download http://
3.2 tibia fracture C2 comparison of treatment methods
Plaster fixed or calcaneal traction stabilizing effect on fracture is poor, difficult to
maintain after the fracture of the anatomic alignment and effective fixed, can be used as life-threatening trauma to save a temporary brake. Although plate fixation, but for fixed C2 fracture of tibia, due to local soft tissue contusion after plate with soft tissue occupying more space, resulting in difficulties in wound closure, easy to cause skin necrosis, bone exposure or osteomyelitis, coupled with intraoperative periosteal stripping broader, bone healing delayed healing or non-high incidence . External
fixator can maximally protect the injured legs of the blood supply for the treatment of open tibial fracture with C2-type skin and soft tissue damage has its own special
advantages , but for the C2 closed tibial fractures are much more difficult to achieve
a good reduction and firm fixation. Axial intramedullary nail fixation by intramedullary nails and broken at both ends of the primary intramedullary fixed, can effectively maintain the fracture of the medial segment of the main block and the
stability of the bone together to overcome the deficiencies of the above methods in the treatment of closed and open Gustilo ?, ? type C2 fracture of the tibia when the
3.3 minimally invasive techniques in the treatment of intramedullary nail use of
Minimally invasive operation of interlocking intramedullary nails include the following aspects: (1) reduction of the fracture. Tibia Ticheng Tri-cylindrical, with
three ridges and three surface, its front side from the crest and the anterior tibial tubercle to the medial malleolus is located just on the skin, easy to reach, but also hard bone, using the above characteristics of the relatively simple fracture reduction is feasible. C2 fracture of tibia significantly more displacement, and fracture of the medial segment of the shorter pieces, the greater the likelihood of rotation occurs, relying solely on the role of soft tissue around the traction difficult to achieve closed reduction. Closed reduction is difficult on the successful use of small incision under direct vision and decisive reduction, can prevent the organization of repeated blood supply restoration caused further damage and bone and soft tissue entrapment between the stump, but also allows simple and effective operation of reset; (2) definition of the point set screw. The top of the tibial tubercle to the tibial plateau articular surface of the formation of a so-called "security zone" , intramedullary nail in this range the
smaller slopes built into the relatively safe area, if the home side on the nail points, or partial, the easily cause of intra-articular structural damage or destruction of tibial
tubercle. The correct set screw point should be located in the middle of the tibial
plateau below the Shaopian inside, from that point into the nail right tibia bone marrow cavity is being ; (3) the choice of reamed or not. Over-reamed to C2 fracture
of tibia already severely damaged the further destruction of bone lining blood
circulation, increasing the chance of the formation of sequestrum. Finite reamed in a manner that the bone marrow cavity of the most narrow at the tibia in 1 / 3 of marrow, moderate in order to blow into the slightly larger than the reamed intramedullary nail
point, even more firmly to the internal fracture fixation, but also to bone film will not suffer too much damage, both to the blood supply and stability of the fracture [9 ~ 10], adapted to C2 closed tibial fracture treatment. Tibial blood supply less than the others
to have more muscle tissue surrounding the bone is rich in C2 for open tibial fractures more likely to have non-healing infections. Unreamed techniques to minimize the
damage to the intramedullary blood circulation, reducing the chance of infection and
fat embolism . Non-reamed intramedullary nailing and marrow cavity wall gap
between the more for the reconstruction of intramedullary blood circulation provided the conditions , is conducive to fracture healing, adapted to Gustilo I and type ?
C2 fracture of tibia treatment; ( 4) fracture of the medial segment of the block blood supply to protect. In order to avoid the limited reamed, and insert nails in fractures of the process of block rotation caused by the loss of blood supply, these operations should
be fully broken and get a temporary clamp on the bit after fixation to proceed.
3.4 The timing of surgery
First of all the important organs for treatment of life-threatening associated injuries,
temporary fixed-fracture, when vital signs were stable after the surgery OK. Open fractures thorough debridement row fixation. Closed fractures generally 8 h after injury as early as possible during surgery, despite obvious swelling of the limb at this
time, but there is no more tendency to calf OCS, early fracture fixation after fracture of the soft tissue to eliminate further damage, which will help the early physical activity and swelling; As the reamed and non-reamed intramedullary nail will cause leg
compartment pressure increased , more drama for the swelling of the closed fractures, first calcaneal traction, and application of mannitol, β-aescin drugs such as
swelling, to reduce swelling after the surgery to be physically in order to prevent the
occurrence of calf OCS.
 Ning Zhijie. Orthopedic Clinical Progress [M]. Beijing: People's Medical Publishing House ,2003,15-16.
 Qin Si River. Minimally invasive - minimally invasive surgery - minimally
invasive techniques to explore ii [J]. Chinese Journal of Orthopedic Surgery, 2005,13 (12) :885-886.
 LUO Xian-zheng, QIU Gui-xing. Intramedullary nail fixation [M]. Beijing:
People's Health Press ,1997,45-46.
 Johner R, Wruch SO.Classification tibia shaft fractures and correlation with results after rigid fixation [J]. Clin Orthop, 1983, (178) :7-25.
 Sun Weijun, DU Hong-wei, ZHENG Yi. Reamed intramedullary nail in
treatment of atrophic nonunion of the tibia [J]. Chinese Journal of Orthopedic
Surgery, 2005,13 (20) :1540-1541.
 Zhao, LI Hong-qin, Li Wei. External fixator in the treatment of complicated open fractures of the Application Technology [J]. Chinese Journal of Orthopedic Surgery, 2005,13 (14) :1079-1081.
 Sun Ye-qing, Chen Wenjun, Gu XJ. Morphology of the proximal tibial intramedullary nailing on the impact of [J]. Chinese Journal of trauma, 2004,20 (10) :592-595.
 Wang Wei Shan, SHI Chen-hui, Kam Por, et al. Intramedullary nail for
treatment of open fractures of tibia and fibula cause analysis and prevention of complications [J]. Chinese Journal of Orthopedic Surgery, 2005,13 (20) :1553-1555.
 Lu Yu, the Yan Hao-jun, SUN Qi-wei, et al. To high-energy trauma-based
treatment of open fractures of the leg [J]. Chinese Journal of Orthopedic Surgery, 2004,12 (20) :1540-1543.
 TIAN, Sun Lei, Wei Wei, et al. Limited reamed intramedullary nailing of closed tibial fracture [J]. Chinese Journal of Orthopedic Surgery, 2003,11 (14) :946-948.
 Hsu Shou-hui, Lin, Zhu Jingbo, et al. Unreamed interlocking intramedullary nail in the treatment of tibial fractures [J]. Chinese Journal of Orthopedic Surgery, 2004,12 (10) :739-741.
 Paul-Rong, Wang Chengwu. Fractures [M]. Beijing: People's Medical
Publishing House ,2004,1148-1154.
 Lam Research, Dong Tian-hua, Yin-Xin Qi, et al. Reamed and non-reamed
intramedullary nailing technique in calf compartment pressure after the deep
observation [J]. Chinese Journal of Orthopedic Surgery, 2002,10 (8): 779 -- 781.
reposted elsewhere in the paper for free download http://