Intramedullary Nailing of Periarticular Fractures

Abstract

Plate fixation has historically been the preferred surgical treatment method for periarticular fractures of the lower extremity. This trend has stemmed from difficulties with fracture reduction and concerns of inadequate fixation with intramedullary implants. However, the body of literature on management of periarticular fractures of the lower extremities has expanded in recent years, indicating that intramedullary nailing of distal femur, proximal tibia, and distal tibia fractures may be the preferred method of treatment in some cases. Intramedullary nailing reliably leads to excellent outcomes when performed for appropriate indications and when potential difficulties are recognized and addressed.

Tibial Plateau Fracture

“…With previous implants, concern for malreduction with intra-articular fractures was due to the nails inherent design flaws that failed to align properly with metaphyseal and epiphyseal segments. Recent advances in the implants have placed multiplanar interlocking screws clustered near the ends of nails to facilitate greater purchase in proximal segments and the ability to lock the interlocking screws to the nail creating a fixed angle construct which theoretically improves stability [115]. With these new improvements intramedullary nailing can be safely used to stabilize proximal intra-articular tibial fractures in which a stable articular block can be created.…”

“…Often, this is performed by placement of independent lag screws proximally and outside of the intended path for the nail, or with buttress plating used with techniques compatible with nailing (Figure 12). Intramedullary nailing can especially be considered in tibial fracture patterns with diaphyseal extension, segmental injuries, or patients with increased risk for wound complications [115,116]. Patients at increased risk for wound complications include patients with morbid obesity, diabetes, peripheral vascular disease, thin skin and compromised soft tissues.…”

“…Contraindications to nailing may include tibial tubercle involvement in the fracture pattern and inability to reconstruct the articular surface outside of the planned nail trajectory. Fractures with tibial tuberosity fragments are poor candidates because the nail can cause a substantial anteriorly directed deforming force [115].…”

Imaging of Pelvic and Femoral Fixation Hardware: Normal Findings and Hardware Failure

“…Modern advancements in intramedullary nail designs to include a greater number of distal interlocking screw options have also increased the success of intramedullary nails for the fixation of distal femur fractures. 99,100 Retrograde intramedullary nailing is typically performed for extra-articular fractures and simple intraarticular fractures. The advantage of retrograde nailing is minimal dissection of the soft tissues and less symptomatic hardware.…”

Far Proximal and Far Distal Tibial Fractures: Management with Intramedullary Nails

“…The evaluation of the quality of soft tissues is key when selecting any method for surgical treatment. Common surgical techniques include plates (either locking or nonlocking), locked intramedullary nails, and external fixators [5,6]. These methods have shown good results in terms of quality of reduction and functional outcomes.…”