Leg: Closed tibia shaft treated with an intramedullary nail

This was a 17 year old with a sports injury sustained during a football tackle.

This is what the leg looked like.

This is what the xrays looked like.

Cast treatment for this fracture was an option.

The disadvantages of casting are:

  1. Casting keeps the muscles and the ankle joint still. This causes stiffness of the joints, and deconditioning and atrophy of the muscles. However, it is possible to recover the muscle strength with physical therapy after the bone has healed.
  2. A long leg cast is necessary for at least the first 2-3 weeks. This type of cast reaches all the way from the toes to the the groin and it can cause some difficulty with hygiene.
  3. Casting does cover the skin. If there is an injury of the skin, it may be difficult to monitor it if it is covered by cast.
  4. Cast adjustments, wedging, etc., are often necessary and can be sometimes painful.
  5. Casting works better in long skinny legs as opposed to short, fatter legs. This is because in shorter fatter legs, the distance between the bone and the outside cast is greater.

The main advantage of casting is avoidance of surgery. Healing is predictable, even though the process may be fussy. One has to check xrays every week for the first 3 weeks; one must make sure there is no angulation in the coronal or sagital plane, and no malrotation of the tibia shaft. Some degree of translation can be tolerated and may result in a prominence (a "lump" on the shin) that is well tolerated, and in any case not uglier than the scars.

For a midshaft tibia fracture, intramedullary nailing is an option. It is the best treatment option, but with one big caveat: infection would be a terrible and costly complication. The risk of infection runs at about 1%, so it is not zero.

I routinely prescribe preoperative antibiotics. I wear a bubble suit. I personally prep the leg, and cover it with sterile adhesive plastic. I change gloves frequently. My technique is meticulous. Despite everything that I do, as a physician I cannot guarantee that an infection will not occur. That is the sad reality of the surgical profession.

Another possible problem with nailing a tibia is anterior knee pain. I have done a lot of these surgeries, and knee pain has not been an issue in my experience. However, chronic anterior knee pain after nailing of tibia fractures is well recognized in the orthopedic literature.

In this particular case, after discussing the options, surgical treatment was chosen by the young man and his parents. A cast, a long leg cast, was not desired. Infection was a risk they were willing to take. Their overriding priority was the quickest return to walking and sports.

During intramedullary nailing of the tibia, a thin wire is drilled into the proximal tibia, followed by drilling over the wire with a cannulated power drill. A nail length is then measured, and a battery-powered reamer is used to mill the inside of the tibia. A titanium rod is then hammered down into the middle of the bone.

The following is a picture taken during surgery. At this point, a wire has been placed in the middle of the tibia, and an xray machine is being used to check the alignment of the fracture, and the length of the nail.

After surgery, early knee and ankle motion was started from day 1 after surgery. The young man was kept on "toe touch weight bearing" precautions for 4 weeks. Staples came out at 2 weeks. After the first month, he was ambulating with a single crutch. Pain went steadily down, and he was back to walking without a limp at the 3 month visit.

Here are the xrays at just under 3 months after surgery.

There is good alignment, callus formation, including at the comminuted fibula, and there was absolutely zero pain.

Here are the xrays at 1 year after surgery. This young man has been active in sports without any complaints whatsoever.

Note that the fibula fracture has healed without any hardware on it. It usually is not necessary to place orthopedic hardware on midshaft fibula fractures.