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Chapter 30 Pediatric Tibial Fractures

T E C H N I Q U E S

A

B

D

E

F

TECH FIG 4 ● A,B. Potential patterns of nail insertion. The standard pattern ( A ) entails one medial and one lateral nail. Alternately, both nails are inserted from the same side to avoid com- promised skin ( B ). In the tibia, the former technique is far easier. C. The nail is placed on the skin, with the tip at the proposed final location, as confirmed radiographically. D. The nail is marked at the fracture site and bent to place the apex at that location. E. When starting a nail, it is helpful to rotate the nail so that the tip points anteriorly, bouncing off the posterior cortex. F. The nail is then turned so that the bend in the nail lies in the coronal plane.

C

■ Cutting the Nails and Wound Closure ■ The nails are then cut, pulling them away from the bone without exceeding the elastic modulus of the nail, so they lie against the bone after they are cut, with about 2 cm of the nail extending out of the bone to facilitate later. ■ Alternately, the nails can be withdrawn a few centi- meters, cut short, and then impacted back down the ■ The bent tip of the nail can be used to assist in reduction as well. ■ To pass the nails across the fracture, it is helpful to consider the initial deformity of the fracture. ■ For example, if the fracture tends to lie in valgus, it may be helpful to pass the medial nail first to apply a varus force. The second nail is then directed across the frac- ture site.

tibia, again leaving 2 cm of exposed nail beyond the entry site. ■ This step is important because if the nails are left too long or are bent out away from the bone, they can cause symptoms from nail prominence before fracture healing. This is especially true medially, where the rod is subcutaneous ( TECH FIG 5 ). ■ The incisions are closed with subcuticular suture, and a posterior splint is applied to allow tissue healing. ■ Care should be taken to stop the nails short of the distal physis and to avoid distraction at the fracture site. ■ When passing the nails, it is often helpful to pass them both to the level of the fracture and sequentially crossing the fracture site. ■ In oblique fractures, the first nail will deform the fracture and make passing the second nail difficult if the first nail is passed all the way down initially. ■ In simple fractures, the order of passage is less important.

TECH FIG 5 ● Instead of cutting the nail under the skin, it can be withdrawn, cut at skin level ( A ), and tamped in to prevent irritation ( B ).

B

A